OutcomesEvaluationoftheBloomProgramOctober2016

Preparedby:BloomProgramevaluatorLisaJacobs,MSW,RSWContactConsultingBloomProgramleadsDavidGardner,BScPharm,ACPR,MSc,PharmDDepartmentofPsychiatryFacultyofMedicineDalhousieUniversityAndreaMurphy,BScPharm,ACPR,PharmD CollegeofPharmacyFacultyofHealthProfessionsDalhousieUniversityContributedtoby:BloomProgramSteeringCommitteeVanessaSherwood,BloomProgramCoordinatorPreparedfor:DepartmentofHealthandWellnessGovernmentofNovaScotiaNovaScotiaHealthAuthorityWebsite:http://bloomprogram.caPublicationdate:October14,2016©2016Allrightsreserved.

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AcknowledgementsEvaluationoftheBloomProgramisaresultoftheinputandcontributionsofmanyindividualsandgroupsfromacrossNovaScotia.Firstandforemost,wewould liketothethankthosewhocreatedthedatauponwhichthisevaluationisbased–theBloom Program participants, pharmacists and other pharmacy staff, physicians,representativesfrommentalhealthandaddictionsorganizationsandagencies,andfamily members. In particular, we would like to acknowledge the tremendousefforts of the lead Bloom pharmacists who facilitated the data collection andhelped to raise awareness of the opportunities for their patients and others toparticipateintheevaluation.Theevaluationplananditsexecutionweredevelopedandat times ledbydifferentprogramevaluators, includingNancyCarter, JenniferDixon, and Lisa Jacobs. In her role with the Nova Scotia Health ResearchFoundation, Nancy Carter developed the initial logic model and related datacollection plans and tools. Jennifer Dixon created an updated comprehensiveevaluationplanandcompletedalargecomponentofit.LisaJacobscompletedthefinal steps of data collection and led the data analysis and report preparation. Adraft of the reportwas reviewed by the BloomProgram steering committee andrepresentativesfromtheNovaScotiaHealthAuthority(MentalHealth&Addictionsand Primary Care) and the provincial government’s Department of Health andWellness.Thefinalreportincludeschangesbasedontheirfeedback.WewouldalsoliketoacknowledgethehelpfulandtimelycontributionstothisreportbyBrittanyWagnerwhowasasummerstudentfromtheCollegeofPharmacysupportedbyastudentship grant from the Drug Evaluation Alliance of Nova Scotia. Finally, wewanttoexpressourtremendousgratitudetoVanessaSherwoodwhoadministeredthe demonstration project from the beginning and worked to support theevaluationprocessthroughout.

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Glossaryoftermsanddefinitions

LeadBloompharmacist The pharmacist at each participating pharmacy who is responsible forimplementation of program policies and procedures as well as program-relatedcommunicationsandqualityassurance.

Longitudinalcare Care provided to patients with one or more long-standing or chronicconditions that benefit from regular follow-up care and support over anextendedperiodof time. It is intended tomeet apatient’smultiplehealthneeds.

Medicationissues Generallycategorizedas:lackoforinadequatetreatmentresponse,adverseeffects (induced by the presence or withdrawal of the medication, amedication interacting with another medication, food or disease), non-adherence(overorunderuse),anduseofmedicineswhennotnecessary.

Medicationmanagement

The activities involved in screening for, identifying, prioritizing andresponding tomedication-related issues; inclusiveofassessment, follow-upcare, therapy monitoring, education, communications, collaboration,research,advocacy,andotheractivitiesthatsupportinformedchoiceaboutmedications.

Mental Health andAddictions*

Mental Health and Addictions Branch within the Nova Scotia HealthAuthority

Patients BloomProgramparticipantswhoarepeople livingwithmentalhealth, andpossiblyaddictionsproblemsinthecommunitysetting.

Pharmacist’s scope ofpractice

Standard 1 of the Nova Scotia College of Pharmacists (Provide PatientCentred Drug TherapyManagement) states: “Pharmacists, in collaborationwith colleagues, patients and other health care professionals, use theirunique knowledge and skills to support the patient on an ongoing basis inmeeting their drug and health related needs to achieve optimal healthoutcomes.”ForafullregulatorydescriptionofpharmacistscopeofpracticerefertothePharmacyActofNovaScotia.

Polypharmacy Sometimes referred to as polytherapy, a term used to indicate the use ofmultiplemedicationsbythesameindividualconcurrently,therebyincreasingthe risk for drug-related morbidity. Inappropriate polypharmacy is a termusedtoclarifythatpolypharmacycanbeagainstthepatient’sbestinterest,representing ineffective therapy,unnecessarypillburden,wastage,adverseeffects,orsafetyproblems.

Socialsupport The component of the pharmacist-patient interaction in which thepharmacistprovidessocialsupporttothepatientthatisnotspecifictotheir

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drug therapy. Social support refers to the various types of support (i.e.,assistance/help)thatpeoplereceivefromothersanditisgenerallyclassifiedinto three major categories: emotional, instrumental and informationalsupport.Thisincludeslisteningtopatients’concernsanddistress,workingtobuild rapport and trust, supporting self-management, providingencouragement and positive feedback, promotion of healthy behaviours,decisionsandactions,andpromotingself-efficacy.

*Where ‘mental health andaddictions’ are referenced, this refers tomental health andaddictions services andsupportsgenerally,notthosespecifictoservicesdeliveredbytheNovaScotiaHealthAuthority.WhenthereportmakesreferencestoMentalHealthandAddictions,thisisareferencetoformalservicesofferedbytheNovaScotiaHealthAuthority.

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ListoftablesandfiguresTables

1. BloomProgramSteeringCommittee2. KeyBloomProgramprojectactivities3. MappingoftheBehaviourChangeWheel’sCOM-BsystemtotheTDFdomains4. Definitionsofinterventionsandpolicies5. Links between the components of the 'COM-B' model of behaviour and the intervention

functions6. BloomProgramcomponents7. EligibilitycriterionforBloompatientenrolment8. Evaluationdatacollectionmethods,sources,andsamplesizes9. DescriptionofpharmaciesapprovedtooffertheBloomProgram10. DemographicsofBloomProgrampatients11. HealthstatusatenrolmentintoBloomProgram12. MedicationissuesatBloomProgramenrolment13. Dispositionofpatientsbasedonchartreview14. Verbatimexamplesofdischargehealthandmedicationissueoutcomes15. PatientsurveyreportofservicesandsupportsreceivedintheBloomProgram16. PhysicalhealthconditionsreportedbyBloomProgramparticipants17. Themedresponsesofwhatpharmacistslikedleastabouttheprogram18. ThemedresponsesofchallengespharmacistsexperiencedprovidingtheBloomProgram19. ThemedresponsesofadviceforprogrammanagersfromBloomProgrampharmacists

Figures

1. BloomProgramgovernancestructure2. TimelineofthedevelopmentandimplementationoftheBloomProgram3. TimelineofBloomProgramoutreachactivities4. BloomProgrampharmacyparticipationtimeline5. PatientcareflowintheBloomProgram6. MentalhealthandaddictionspatientgroupsexpectedtobenefitfromtheBloomProgram7. MapofBloomProgrampharmaciesinNovaScotia8. Mentalandphysicalhealthproblemsatenrolment9. Medicationsatenrolment10. SourceofreferraltotheBloomProgram11. Distributionofthenumberoffollow-upvisitsbetweenpatientsandpharmacists12. Frequencyanddurationofmeetingsbetweenpatientsandpharmacists13. Distributionofpurposesoffollow-upvisitsbetweenpatientsandpharmacists14. Howpharmacist-patientinteractionswereconducted15. Typeofserviceandsupportaccessedthroughpharmacistnavigationalsupport16. Frequencyofmedicationissuesidentifiedbypatientsatenrolment17. Patient-reportedratesofhealthproblemoutcomesatdischarge18. Pharmacists’perceptionsofpatientcareoutcomes19. (A)PatientratingoftheoverallqualityoftheBloomProgram.(B)Frequencyofpatientswho

wouldrecommendtheBloomProgramtoothers(%)

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Tableofcontents

Acknowledgements.................................................................................................................i

Glossaryoftermsanddefinitions...........................................................................................ii

Listoftablesandfigures.........................................................................................................iv

Tableofcontents....................................................................................................................v

Executivesummary...............................................................................................................vii

Introduction...........................................................................................................................1

BloomProgram......................................................................................................................2Organizationalstructureandstaffing...............................................................................................3Keyprojectactivities........................................................................................................................4ProgramCharter...............................................................................................................................5Theory..............................................................................................................................................8Programcomponents.....................................................................................................................10Pharmacyparticipation..................................................................................................................11Qualityassurance...........................................................................................................................14PatientcareintheBloomProgram.................................................................................................14Eligibility,referralandenrolment...................................................................................................15Assessmentandcareplanning.......................................................................................................16Patientcarefollow-up....................................................................................................................17Discharge.......................................................................................................................................18

EvaluationoftheBloomProgram.........................................................................................19Evaluationpurpose........................................................................................................................19Programlogicmodel......................................................................................................................19Programoutcomesmeasured.........................................................................................................19Methodology.................................................................................................................................20Administrativedata........................................................................................................................20Surveys..........................................................................................................................................21Interviews......................................................................................................................................22Limitations.....................................................................................................................................22Expectations..................................................................................................................................23

Evaluationfindings...............................................................................................................24DescriptionofBloomProgrampharmacies.....................................................................................24Patientdemographics....................................................................................................................25Programdata.................................................................................................................................30Programcompletion.......................................................................................................................31

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Outcome1:AccessandNavigation.................................................................................................33Keyfindings........................................................................................................................................33Analysis..............................................................................................................................................34IncreasedAccesstoBloomProgramPharmacists.............................................................................34IncreasedAccesswithExtendedHoursofOperation........................................................................39IncreasedAccesstoMentalHealthandAddictionsServicesandSupports.......................................40IncreasingAccessThroughNavigationalSupport..............................................................................44Navigationactivitiesbasedonchartandsurveydata.......................................................................44Improvingsystemefficienciesviapharmacist-facilitatedaccesstoothermentalhealth,addictions,andphysicianhealthcareservicesandsupports...............................................................................46Extendingnavigationalsupporttonon-BloomProgrampatients.....................................................48Navigationalsupportincreasesinter-professionalnetworking.........................................................48

Outcome2:MedicationManagement............................................................................................50Keyfindings........................................................................................................................................50Analysis..............................................................................................................................................50ResolutionofMedicationIssues........................................................................................................50Medicationmanagement:successstories.........................................................................................63HolisticMedicationManagement......................................................................................................64ImprovingPharmacist’sPatientCare.................................................................................................65IncreasedAwarenessofMedications................................................................................................65PatientEmpowerment.......................................................................................................................66RelationshipBuilding.........................................................................................................................67IndividualswhodidnotcompletetheBloomProgram.....................................................................68

Outcome3:CommunicationandCollaboration..............................................................................69Keyfindings........................................................................................................................................69Analysis..............................................................................................................................................69Communications................................................................................................................................70Collaboration.....................................................................................................................................74

Outcome4:RoleofthePharmacist................................................................................................77Keyfindings........................................................................................................................................77Physicians...........................................................................................................................................79Pharmacists........................................................................................................................................80

ProgramFeedback.........................................................................................................................82Patientfeedback................................................................................................................................82Physicianfeedback.............................................................................................................................85PharmacistFeedback.........................................................................................................................89

Discussion............................................................................................................................95

Implications..........................................................................................................................96

Recommendations................................................................................................................97

Appendices...........................................................................................................................98

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ExecutivesummaryTheOutcomesEvaluationoftheBloomProgrampresentedinthisreportestablishesthattheBloomProgram demonstration project increased and enhanced mental health and addictions care andservicesforNovaScotians.

TheBloomProgramisacommunitypharmacydemonstrationprojectdesignedtoincreaseandimprovementalhealthandaddictionscare forNovaScotians.The27-monthdemonstrationproject, started inSeptember2014,wasfundedthroughtheNovaScotiaMentalHealthandAddictionsStrategy,TogetherWeCan.FundingforthedemonstrationprojectendsinDecember2016.

Seventypharmacists,andpharmacystaff,in13ruraland10urbancommunitypharmaciesacrossNovaScotia enrolled 221 Nova Scotians living with mental illness and addictions problems in the BloomProgram. The key evaluation outcomes are centred on the core activities of the Bloom Program andinclude: 1) patient-centredmedicationmanagement services providedby pharmacists; 2)access andnavigation of the health care system; 3) collaboration and communication with other health careprofessionals and community organizations by pharmacists; and 4) perceptions of the pharmacists’rolesinanoptimizedscopeofpracticeinmentalillnessandaddictionscare.Thiswasamixedmethodsevaluation. Data sources included interviews (n=41), surveys (n=100), and 201 anonymized patientcharts. Evaluation participants included patients, physicians, pharmacists and pharmacy staff, andmembersofmentalhealthandaddictionsorganizationsandservices.

Bloom Program patients closely mirror the characteristics of the mental health population in NovaScotia. Anxiety (69%), depression (63%), and sleep (36%) disorders were the most frequent patient-identifiedmentalhealthproblems,followedbysubstanceusedisorders(16%),PTSD(14%)andbipolardisorder (11%). The most commonly used medications were antidepressants (72%), benzodiazepinesandrelateddrugs(53%),andantipsychotics(29%);68%ofpatientsweretakingmultiplepsychotropics.Physical health problems (e.g. pain& neurological disorders: 38%; cardiovascular disease: 28%)wereprevalent: 71% of the participants were taking multiple physical health medications. Overall, BloomProgrampatientsweretakinganaverageof5.5prescribedmedications(range0to24).Useofnicotine(39%),alcohol(38%),andmarijuana(18%)werecommon.Mostpatients(81%)enrolledintheprogramtoworkwiththeirBloompharmacisttooptimizetheirmedicationregimeninordertoachieveimprovedsymptomaticandfunctionalhealthoutcomes.Inaddition,24%identifiedmanagingadverseeffectsand13%identifiedhelpwithdiscontinuingmedicationasreasonsforenrollment.

Four in fivemedication issues (e.g., unresolved symptomsor impaired functioning, adverse effects,overmedication,dependence,etc.)werefullyresolvedorimproved.

Efficiencies in care by pharmacists working collaboratively with patients and physicianssupported the high rate of successful medication and health outcomes. Bloom Programpatients increased their medication and health knowledge and accessed and utilizedpharmacists effectively. Physicians viewed the Bloom Program as promoting patient self-efficacy and facilitating the avoidanceof negative, possibly costly, health andmedicationissues.

Pharmacists helped patients to successfully access and navigate the health care system and otherservicesintheircommunitiesformentalhealth,addictions,andphysicalhealthneeds.

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BloomProgrampharmacistswererequiredtoconductanenvironmentalscanoftheirlocalmental health and addictions communities to support patient navigation. Collectively,pharmacistsrecorded153meetingsand identified320 localmentalhealthandaddictionsprograms, services, and supports before offering the Bloom Program. 61% of patientsreportedthattheirpharmacisthelpedthemaccessothermentalhealthservices;42%werehelped toaccess services for theirphysicalhealth; 25%werehelped toaccess addictionscare; and, 47%were assisted in finding other services and supports in their community.Almost three of every four patients surveyed (72%) reported being more aware ofcommunityresourcesand47%wereabletoaccessthemfasterthanpreviously.

The Bloom Program was easily accessible for patients in their community pharmacies throughregularly scheduled as well as on-demand care provided either through face-to-face or telephoneinteractionsthatpatientsaccessedonweekdays,evenings,andweekends.

BloomProgrampatientswerecommittedtotheprogramwith90%comingbackaftertheirinitial assessment with their pharmacist, which averaged 50 minutes and was critical topatient-centred care, collaboration, and longitudinal follow-up. The average number ofvisits was five-six per patient over six months. Most meetings were approximately 20minutesandvariedbasedonpatientneed.Insomecases,pharmacistsmadehomevisits.

TheBloomProgramofferedoptionsinpatients’care,particularlyforthoselivinginruralarea.

The availability of the Program in local community pharmacies minimized the need fortravelwith itsassociatedcostsand inconveniences. Itprovidedpatientswith interimcarewhile they were awaiting access to other mental health and addictions services ortransitioningfromonelevelofcaretoanother.Socialsupportprovidedbypharmaciststhatcoincided with the medication management activities generated significant appreciationfrom patients. Many Bloom Program patients said they were grateful to find a caring,compassionatehealthprofessionalattheirlocalpharmacywhomadethemselvesavailabletolisten.PhysiciansechoedthisbenefitoftheProgram.

Access to care increased. The program provided an alternative care option for some patientswhowerenototherwiseengagedincare.

Somepatientswereisolatedand/orunwillingtoaccessformalcareforavarietyofreasons,includingstigmaandunsatisfactorypastexperiences.Thepharmacyofferedasafe,neutralplace for them to seek medication management and social support, and ultimately, re-integrationtoprimarycareand/ormentalhealthandaddictionsservices.

Bothphysiciansandpharmacistsacknowledgedtheimportanceofcommunicationandcollaborationandwantedmore.

MostphysicianssupportedtheBloomProgramanditsfocusonenhancedcollaborationastheyrecognizedandutilizedpharmacists’psychotropicmedicationexpertiseandseearolefor pharmacists in helping patientsmanage theirmedicationswithin a collaborative caremodel. Patients expressed sentiments around better care beingachieved throughcollaborationandweredirectiveinrequestingmore.Theevaluationfoundmanyexamplesof effective communication and collaboration between pharmacists and physicians andthereareopportunitiestoworktoenhancethenature,mechanisms,type,andfrequencyof

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communication among pharmacists and the patient’s circle of care, including familyphysiciansandspecialists.

Educationwasacoreactivityprovidedbypharmaciststopatientsandtheircircleofcare.

17%ofpharmacists’patientcareactivitieswereeducationfocused.Patientsandphysicianscommentedfrequentlyonthevalueattributedtothepharmacist’ssharingofinformation,often in support of informed patient treatment decisions. Seven of 10 patients statededucationactivitiesalsoinvolvedfamilyandothercaregivers.

Thehighqualityof theBloomProgramwaswidely recognizedandpatientsstronglyendorsed it forothers.

Patientsviewed theprogramhighlywith89%rating itasexcellent toverygoodand92%indicatedtheywouldrecommendtheProgramtoothers.

In summary, the Bloom Program increased the capacity and care provided by pharmacists, who areaccessible12ormorehoursperday,oftensevendaysaweek,throughoutruralandurbancommunitiesinNovaScotia.TheProgramsupportedbetterhealthcareandbetterhealthandmedicationoutcomes.Itprovidedcomprehensiveassessmentsofmedicationandrelatedhealthissues,regularfollow-upcare,ongoingcollaborationwithotherhealthcareproviders,andnavigationandsocialsupportforpatients.

The evaluation demonstrated that patients, physicians, and pharmacists want to see the BloomProgram extended, expanded, and better promoted to allow for improvements to bemade and foraccess to increase.This canbeachievedby supporting the transitionof theBloomProgram fromthisdemonstrationprojecttoamoresecureprogram,withcontinuedevaluation,thatisstrategicallyalignedwithothercomplementaryinitiativesinprimarycareandmentalhealthandaddictionsservicesinNovaScotia.

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Introduction

TheBloomProgram (formally referred to as theMentalHealth andAddictions Community PharmacyPartnershipProgram)isacommunitypharmacyprojectdesignedtoincreaseandenhancementalhealthand addictions services for Nova Scotians. Pharmacists work closely with people living with mentalhealthandaddictionsproblemstoprovidecomprehensiveconsultationandfollow-upcareto improveand/or resolve medication management issues specific to mental health and addictions and relatedphysical health. BloomProgrampharmacists help patients navigate themental health and addictionssystemtoaccessotherservicesandsupportsandcollaboratewithotherhealthcareproviderssuchasfamilyphysicianstoaddressesmedicationmanagementissues.

Funded under the Nova ScotiaMental Health and Addictions strategy, TogetherWe Can, the BloomProgramwasinitiatedinMarch2014anditisfundeduntilDecember31,2016.Duringtheactiveprojecttimeperiod,221NovaScotianslivingwithmentalhealthandaddictionsproblemsaccessedtheprogramasprovidedby23BloomProgrampharmacieslocatedin13ruraland10urbancommunitiesacrossNovaScotia.

This report presents the findings of an evaluation of the project’s expected short-term, and severalmedium-term,outcomes.Italsopresentssomehighlevelfindingsrelatedtoareaswheretheprogramcouldbestrengthenedinordertomaximizeitsimpactshoulditbeexpanded.

Theinformationinthisreportisdividedintothefollowingmajorsections:

Section1: DescriptionoftheBloomProgram:background,organizationalstructureandkeyactivities;patientcareprocesses.

Section2: Evaluationoutline:logicmodel,outcomes,methodologyandlimitations

Section3: Evaluationfindings(outcomesandprogramfeedback)

Section4: Discussionoffindings

Section5: Implications

Section6: Recommendations

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BloomProgram

NovaScotiaContext

TheBloomProgramwasdevelopedoutofan identifiedneed in theprovince to improveservicesandsupports for people living withmental health and addictions problems. In 2010, the Government ofNovaScotiareneweditsfocusonstrengtheningmentalhealthandaddictionsservicesandappointedaMentalHealthandAddictionsStrategyAdvisoryCommitteetoidentifykeyareaswhereimprovementswere needed. The Committee reported thatNova Scotia had higher prevalence ofmood and anxietydisorders,alcoholmisuse,bingedrinking,anddailysmokingcomparedtootherCanadiansandidentifiedsignificant local and system-wide service gaps. Furthermore, among this highly stigmatized andvulnerable population,many had concurrentmental health and addictions disorders, chronic diseasecomorbidity,andhighuseratesofpsychotropicmedication.ThefindingsfromtheAdvisoryCommitteeinformed the government’s five-yearmental health and addictions strategy,TogetherWe Can,whichwasreleasedinApril2012.

Duringthissametimeperiod(2013),Drs.DavidGardnerandAndreaMurphyatDalhousieUniversity’sDepartmentofPsychiatryandCollegeofPharmacywereimplementingaprogramtheyhaddevelopedfor Nova Scotia pharmacists known as More Than Meds.1Briefly, More Than Meds was a capacity-buildingprojecttosupportpharmacistsinprovidingenhancedmentalhealthcareforpeoplewithlivedexperience of mental illness. It consisted of multiple components that included an education andtrainingdaythatpartneredcommunitypharmacistswithcommunitymemberswithlivedexperienceofmental illness, pharmacist-led educational outreach in the community, and relationship buildingbetweenpharmaciesandlocalmentalhealthadvocacyorganizations.Theprogramdevelopedanetworkof35trainedpharmacistswho,usingatrain-the-trainermodel,establishedacommunityofpracticeviaawebsite,regularcommunications,anewsletterandtheuseofsocialmedia.2

TheconceptfortheBloomProgramevolvedfromtheexperiencesandfeedbackgainedfromtheMorethanMedsprogram.Bothprogramsarerootedintheknowledgethatpharmacistsareoneofthemostaccessiblehealthcareprovidersincommunitiesintermsoflocationandhoursofoperation,withaccessavailable in many rural and remote communities. Their community-based setting, along with theirexpertise in psychotropicmedications,make themuniquely positioned health care professionalswhocanhelpbridgesomeofthegapsinthehealthsystemandimprovepatientoutcomesinmentalhealthandaddictions.Bothprogramsalsoseektosupportpharmaciststoworkoptimallywithintheirscopeofpractice.3IntheBloomProgramthismeantthatpharmacistsprovidemorecomprehensive,longitudinal(over time rather thanone timeonly) patient care that includes assessment, planning and follow-up;

1Seewww.morethanmeds.comformoreinformation.2Murphy,A.L.,Gardner,D.M.,Kutcher,S.P.,&Martin-Misener,R.(2014).Atheory-informedapproachtomentalhealthcarecapacitybuildingforpharmacists.InternationalJournalofMentalHealthSystems,8:46.3 Standard 1 of the Nova Scotia College of Pharmacists (Provide Patient Centred Drug Therapy Management) states: “Pharmacists, incollaborationwithcolleagues,patientsandotherhealthcareprofessionals,usetheiruniqueknowledgeandskillstosupportthepatientonanongoingbasisinmeetingtheirdrugandhealthrelatedneedstoachieveoptimalhealthoutcomes.”Forafullregulatorydescriptionofthescopeofpracticeofapharmacist,refertothePharmacyActofNovaScotia.

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providing support and working more collaboratively with family physicians, psychiatrists, as well asothermentalandphysicalhealthcareproviders.

In lightof theprovince’s renewedfocuson improvingmentalhealthandaddictions,Drs.GardnerandMurphy submitted a proposal to the provincial government under the province’s mental health andaddictions strategy to implement the Bloom Program demonstration project. The proposal wasapprovedinMarch2014asaninitiativeunderthestrategy’skeypriorityarea:Interveningandtreatingearlyforbetterresults.Implementationoftheprogrambeganimmediately.

Organizationalstructureandstaffing

Organizationalstructure

The overall implementation andmanagement of the Bloom Programwas carried out by the projectImplementation Team: two project leads (Drs. David Gardner and Andrea Murphy), one projectcoordinator/manager(Ms.VanessaSherwood),andpart-timesupportstaff(variousstudents).ABloomProgram steering committee, which met three times per year, provided oversight of the strategicdirection of the program and provided feedback and advice to the project leads regarding programactivities, quality, outcomes, and evaluation. Agencies, organizations and related stakeholder groupsrepresentedonthecommitteearelistedinTable1andthenamesoftheindividualrepresentativescanbefoundinAppendixA.

Theprogram’sgovernancestructureisshowninFigure1.Theprogramcoordinator/manager,identifiedas the Administrator, provides a central link to the implementation team, pharmacies, and steeringcommittee,andalsotoadhocpeer-to-peersupport.Peersupportwasidentifiedasapotentialneedforsome pharmacies that were offering the program but that may have been having difficulties withimplementing ormaintaining its policies and procedures, for example, documentation standards. Thesteering committee liaisedwith theDepartmentofHealth andWellnesswhowere active, non-votingmembersofthesteeringcommittee.

Table1:BloomProgramsteeringcommittee

Organizations Representatives

PharmacyAssociationofNovaScotia 1

NovaScotiaCollegeofPharmacists(non-voting) 1

Psychiatrist 1

Familyphysician 1

Communitymembers representingpeople livingwithmental illnessandaddictionsproblems

2

DepartmentofHealthandWellness 1

Communitypharmacists 2

NovaScotiaHealthAuthority,Addictions&MentalHealth 1

Ex-officiomembers(non-voting) 4

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Figure1:BloomProgramgovernancestructure

Independent of the operations of the program, a part-time project evaluator was responsible formanagingandconductingevaluationactivities.ThispositionwasfilledbyJennDixonfromJune2015toMay 2016, and Lisa Jacobs from June 2016 to current. Several students, fromDalhousie’s College ofPharmacy,FacultyofHealthProfessions,contributedtoprogramdevelopmentand implementationaswellasevaluation.Twopharmacistswerehiredtosupportthecreationoftheevaluationchartreviewbycompletingthetranscribingofpatientchartinformationtoananonymizeddatabase.

Keyprojectactivities

DevelopingandimplementingtheBloomProgramprojectwasaccomplishedbycompletingkeyprojectactivitiesoutlinedinTable2.AdetailedtimelineofactivitiesandmilestonescanbefoundonFigure2.

Table2:KeyBloomProgramprojectactivities

Activity Timeframe

1 HireprojectstaffandbuildtheSteeringCommittee Earlyprojectperiod

2 ConductcommunicationandoutreachaboutBloomProgram Earlyprojectperiod

3 RecruitpharmaciestodelivertheBloomProgram Earlyprojectperiod

4 DelivertrainingsessionsforLeadBloomProgrampharmacists Throughoutprojectperiod

5 SupportpharmaciesandpharmaciststodelivertheBloomProgram Throughoutprojectperiod

6 Conductevaluationactivities Throughoutprojectperiod

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Significanttimewasspentearlyonintheprojecttravellingtocommunitiestointroducetheprojecttokeystakeholders(pharmacistsandpharmacyowners,familyphysicians,psychiatristsandothermentalandphysicalhealthcareprofessionals,peoplelivingwithmentalhealthandaddictionsproblems,familymembersandcommunityorganizations).Manyofthesemeetingstooktheformatofpublicforumsandinformationsessions.Thesesessionswereconductedbythe implementationteamand,aspharmacieswererecruited,bypharmacists.Figure3providesatimelineofthekeyoutreachactivities.

ProgramCharter

The Bloom Program is rooted in a Program Charter that was developed by the program leads andreviewed and amended by the steering committee. The Charter specifies the principles andcommitmentsoftheprogramthateveryBloompharmacyisexpectedtoadheretowhendeliveringtheprogram.Theprojectprinciples,listedhere,shapetheprogram’skeycomponents.

Patient-centredCommunityorientedEvidence-informedHolisticCollaborativeDedicatedtoinformedpatientcareSupportiveofpatientrecoveryanddischargefromtheprogram

AcopyoftheBloomProgramCharterisincludedasAppendixB.

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Figure2:TimelineofthedevelopmentandimplementationoftheBloomProgram

Bloom Program Demonstration Project Development Timeline

2014 2017 Mar Aug Jun Nov Sep

1st Bloom Training Session

1st Bloom Pharmacy

2nd Bloom Training Session 3rd Bloom Training Session Patient enrollment put on hold

DHW Funding

Project Coordinator hired

Steering Committee formed

Tariff negotiations Health authority re-design DHW

demonstration funding ends

Bloom Program Demonstration Project

Bloom Pharmacy recruitment

Bloom Program evaluation

Bloom patient enrollment Bloom demonstration project patient care and community support activities

Program Evaluator 1 hired Program Evaluator 2 hired

DHW re-design

2016 2015

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Figure3:TimelineofBloomProgramoutreachactivities

Timeline of Bloom Program Presentations

Spryfield Fam Prac Abbie Lane Inpatient unit

Public

Professional

Mental Health Coalition of Nova Scotia

2014 2016 2015 2016 Oct Jun Nov Jun

Public Forum Spryfield

Alcare, Halifax

PTSD Awareness Day, Antigonish

Public & livestream event Halifax Public Library

Public forum N. Sydney

MH Strategy Advisory Committee meeting

Pharmacy Association Annual meeting

North End CHC

Univ. Sydney, Aus.

IWK Emergency Mental Health Team Bayer’s Road CMHT Collaborative Care Clinic, Halifax

Dalhousie CME annual conference

Dalhousie Social Work Clinic

CPhA National Conference

Laing House

Mar

ECFH

Cobequid Mental Health

CMHA Truro

Public Good Society of Dartmouth

Spryfield Fam Med

IWK Garron Centre

Dartmouth Community Health Board

Elmsdale Fam Prac

Laing House

Univ. Melbourne, Aus.

Public forum Antigonish Public forum Port Hawkesbury

Public forum Halifax Public forum Dartmouth

NS Primary Care Conference

OTP Central Zone

Cobequid Community Health Board

Lunenburg Family Health Dawson Centre, Bridgewater

Mental Health Services, Eastern Zone

ORTP Western Zone

Doctors NS

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Theory

TheBloomProgramisunderpinnedbyatheoreticalmodelofbehaviour,theBehaviourChangeWheel(BCW),4,5amodelthatwasalsousedinMoreThanMeds6capacitybuildingproject.AtthecentreoftheBCW is the model of behaviour known as the COM-B (C=capability, O=opportunity, M=motivation)(Table 3). Within capability, there is psychological and physical capability; for motivation there isreflectiveandautomaticmotivation;andfinally,inopportunitythereisphysicalandsocialopportunity.The COM-B is also mapped with the Theoretical Domains Framework (TDF). The TDF consists of 14domainsthatserveas influencesonbehaviour.Forexample, ifpharmacistshaveknowledgeandskills(TDFdomains)withrespecttomanagingantidepressantpharmacotherapy,theywouldbeconsideredtohavethepsychologicalcapability(CoftheCOM-B).Informationsuchasthisisthenappliedtodesigninginterventions.TheBCWhasbeenmappedwithvarious interventionfunctionsandpolicycategoriestohelpwithinterventiondesign(Tables4and5).Withtheexampleofknowledgeandskills,ifpharmacistswere experiencing struggles in these domains, education and training could be used to improveknowledgeandskills(Table5).Thedesign,development,andimplementationoftheBloomProgramisbased on the implementation team’s knowledge and experience of the influences on behaviour andpotentialinterventionsthatmayimpactvariousareasoftheCOM-B.Thisknowledgeandexperiencehasbeen built by appraisal of existing published and grey literature, international collaborations, tacitknowledge,andevidencefromlocalprograms,includingMoreThanMeds.3,7,8,

Table3:MappingoftheBehaviourChangeWheel’sCOM-BsystemtotheTDFdomains1,2

COM-Bcomponent

TDFDomain

Capability Psychological Knowledge Skills

Memory,AttentionandDecisionProcesses

BehaviouralRegulation

Physical Skills Opportunity Social SocialInfluences

Physical EnvironmentalContextandResources Motivation Reflective Social/ProfessionalRole&Identity BeliefsaboutConsequences

BeliefsaboutCapabilities Intentions Optimism Goals

Automatic Social/ProfessionalRole&Identity Optimism Reinforcement Emotion

4Cane J,O'ConnorD,MichieS.Validationof the theoreticaldomains framework foruse inbehaviourchangeand implementation research.ImplementSci.2012;7:37-5908-7-37.doi:10.1186/1748-5908-7-37;10.1186/1748-5908-7-37.5Michie S, van Stralen MM, West R. The behaviour change wheel: A new method for characterising and designing behaviour changeinterventions.ImplementSci.2011;6:42.doi:10.1186/1748-5908-6-42.6MurphyAL,GardnerDM,KutcherSP,Martin-MisenerR.Atheory-informedapproachtomentalhealthcarecapacitybuildingforpharmacists.IntJMentHealthSyst.2014;8(1):46-4458-8-46.eCollection2014.doi:10.1186/1752-4458-8-46;10.1186/1752-4458-8-46.7Murphy AL,Martin-Misener R, Kutcher SP, Gardner DM. Pharmacists' performance in a telephone-based simulated patient study after amentalhealthcapacity-buildingprogram.IntJClinPharm.2015;37(6):1009-1013.doi:10.1007/s11096-015-0171-7[doi].8MurphyAL,PhelanH,HaslamS,etal.Communitypharmacists’experiencesinmental illnessandaddictionscare:Aqualitativestudy.SubstAbuseTreatPrevPolicy.2016;11:6DOI:10.1186/s13011-016-0050-9.

9

Table4:Definitionsofinterventionsandpolicies

Interventions Definition Examples

Education Increasingknowledgeorunderstanding Providinginformationtopromotehealthyeating

Persuasion Usingcommunicationtoinducepositiveornegativefeelingsorstimulateaction

Usingimagerytomotivateincreasesinphysicalactivity

Incentivisation Creatingexpectationofreward Usingprizedrawstoinduceattemptstostopsmoking

Coercion Creatingexpectationofpunishmentorcost

Raisingthefinancialcosttoreduceexcessivealcoholconsumption

Training Impartingskills Advanceddrivertrainingtoincreasesafedriving

Restriction Usingrulestoreducetheopportunitytoengageinthetargetbehaviour(ortoincreasethetargetbehaviourbyreducingtheopportunitytoengageincompetingbehaviours)

Prohibitingsalesofsolventstopeopleunder18toreduceuseforintoxication

Environmentalrestructuring

Changingthephysicalorsocialcontext Providingon-screenpromptsforGPstoaskaboutsmokingbehaviour

Modelling Providinganexampleforpeopletoaspiretoorimitate

UsingTVdramascenesinvolvingsafe-sexpracticestoincreasecondomuse

Enablement Increasingmeans/reducingbarrierstoincreasecapabilityoropportunity1

Behaviouralsupportforsmokingcessation,medicationforcognitivedeficits,surgerytoreduceobesity,prosthesestopromotephysicalactivity

Policies Definition Examples

Communication/marketing

Usingprint,electronic,telephonicorbroadcastmedia

Conductingmassmediacampaigns

Guidelines Creatingdocumentsthatrecommendormandatepractice.Thisincludesallchangestoserviceprovision

Producinganddisseminatingtreatmentprotocols

Fiscal Usingthetaxsystemtoreduceorincreasethefinancialcost

Increasingdutyorincreasinganti-smugglingactivities

Regulation Establishingrulesorprinciplesofbehaviourorpractice

Establishingvoluntaryagreementsonadvertising

Legislation Makingorchanginglaws Prohibitingsaleoruse

Environmental/socialplanning

Designingand/orcontrollingthephysicalorsocialenvironment

Usingtownplanning

Serviceprovision Deliveringaservice Establishingsupportservicesinworkplaces,communitiesetc.

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Table 5: Links between the components of the 'COM-B' model of behaviour and the interventionfunctions

Model ofbehaviour(COM-B)andsources

Education

Persua

sion

Incentivisa

-tion

Coercion

Training

Restric

tion

Environ-

men

tal

restructuri

ng

Mod

ellin

g

Enab

lemen

t

C-Ph √ √

C-Ps √ √ √

M-Re √ √ √ √

M-Au √ √ √ √ √ √

O-Ph √ √ √

O-So √ √ √

Programcomponents

TheoverallgoaloftheBloomProgramistoimprovethehealthandqualityoflifeofpeoplewithmentalillness and addictions living in Nova Scotia. To achieve this, the program was based on nineinterconnectedcomponentsthatreflecttheprogram’sprinciplesandcommitments.ThesecomponentsarelaidoutinTable6.

Table6:BloomProgramcomponents

Component Componentdescription

1. Linkages Developingandmaintaininglinkageswithcommunitymentalhealthorganizations.

2. Outreach Providingoutreachactivitiesbythepharmacyanditspharmaciststosupportthelocalmentalhealthcommunity.

3. Collaboration Enhancingcollaborationandcommunicationwithotherhealthproviders,especiallyprimarycareandaddictionsandmentalhealthcareservices.

4. Resources Developingalocalmentalhealthknowledgeexchangeresource“centre”.

5. Training Providingprogram-relatededucationandtrainingtoallpharmacyteammembers.

6. Patientregistration

Enrolmentoftargetedeligiblepatientsbypharmacistswiththeprogram.

7. Enhancedpatientcare

Providingenhancedpatientsupportservicesincluding:• Mentalhealthandaddictionssystemsnavigation,resourcesandaccesssupport• Triageofcaretoappropriatehealthprovidersasindicated• Indepthmedicationtherapymanagementinvolvingenhancedmonitoringand

overallassessmentofaddictionsandmentalillnessaswellasphysicalhealthdisordersandtheirtreatments

• Collaborationwithpatients,familiesandothercareproviderstoidentifyandresolvementalandphysicalhealthproblems

• Educationconsultationsregardingmentalhealthdisordersandtheirtreatment• Real-timesupportinpersonorviatelephoneduringpostedpharmacyoperations

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Pharmacyparticipation

i. Pharmacyrecruitmentprocess

Several methods were used to identify pharmacies to participate. Invitation went to communitypharmacists who participated in More Than Meds project in the spring of 2014 and communitypharmacists known to be interested inmental illness and addictions carewere also informed of theopportunitytoparticipate.Thishelpedtoestablishthefirstroundofninepharmaciesfromacrosstheprovincetocompletethefullnine-stepapplicationprocess(seebelow)bythefallof2014.TheprojectleadsalsometwithstaffintheDepartmentofHealthandWellnesstoidentifypreferredlocationsintheprovince for which the service could be offered. Opportunities to participate were also extendedthroughthePharmacyAssociationofNovaScotia:theannualconferenceandtheweeklye-newsletter.Interestedpharmacies could complete an expressionof interest formon theBloomProgramwebsiteandpharmacistswereencouragedtocontacttheprojectleadsorprogramcoordinator.

Theinitialobjectivewastorecruit20pharmaciesandthistargetwasincreasedslightlyastheprogram’simplementation evolved. A total of 28 pharmacies completed the application process and wereapprovedtooffertheBloomProgramattheirpharmacies.WhenpatientenrolmentwasputonholdonJune30,2016, therewere23pharmaciesoffering theprogram in theircommunities.Fivepharmacieshadwithdrawnfromtheprogram: twopharmacieswithdrewwithinmonthsof theirapproval toofferthe program primarily due to difficulties with patient recruitment; two other pharmacies stoppedofferingtheprogrambecauseofachangeinservicefocus;and,thefifthpharmacycloseditsbusiness.One of the 23 active pharmacies had not yet enrolled any patientswhen the evaluation process hadstarted.Figure4providesatimelineofBloomProgrampharmacyparticipation.

8. Qualityassurance

Pharmaciesparticipatingintheprogramwillmaintainrecordsdemonstratingtheadherencetotheprogram’scriticalcomponents.Participatingpharmacieswillapplytocontinuewiththeprogramevery2years.

9. Programevaluation

AcomprehensiveevaluationoftheBloomProgram.

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Figure4:BloomProgrampharmacyparticipationtimeline

Figure 4: Bloom Program Pharmacy Participation Timeline

2014 2016 June Apr Aug Dec

1st Bloom Training Session

2nd Bloom Training Session

2015

101 103 108

104 107

Sept

3rd Bloom Training Session

105 110 111

112 113

102 106 109

114 115 116

117

118

119

120

122 123 124

125 121 126

127

128

Pharmacy Approval

Pharmacist Training Sessions

Pharmacy Withdrawal

103 105 108

107

113

13

ii. Pharmacyapplicationprocess

PharmacistswhowereinterestedindeliveringtheBloomProgramhadtofirstcompleteanapplicationprocessconsistingofninerequiredactivities.Oncealloftheseactivitiesweresuccessfullycompleted,apharmacy was considered to have met the eligibility criteria and given permission by the programimplementationteamtobegintoacceptpatients.Thefollowingisanabridgedchecklistoftheeligibilityrequirements.AmoredetaileddescriptionofeachcanbefoundinAppendixC.

BloomProgrampharmacyrequirements

R ConductlocalenvironmentalscanR DemonstratelinkswithlocalmentalhealthandaddictionssupportgroupsR Provide a mental health and addictions resource centre within the

pharmacyR InformlocalhealthprovidersabouttheBloomProgramatyourpharmacyR InformthepublicthattheBloomProgramisavailableatyourpharmacyR Maintainanin-pharmacyhealthprofessionallibraryR Participate in comprehensive live training of a nominated Bloom

pharmacistleadR CompletetrainingofotherpharmacystaffR Establish policies and procedures within the pharmacy related to the

BloomProgram

Completionoftheseactivitieswaspartoftheprogram’squalitycontrolprocessinthatithelpedensurethatapharmacywasfullypreparedtodelivertheprogramonceitwasapproved.Keythemesamongtherequirements were the demonstration of the pharmacist’s familiarity with local mental health andaddictionsservicesandsupportsthattheycoulddirectand/orreferBloomProgrampatientstoinordertosupportpatientoutcomes;conductingoutreachactivitieswithlocalservicesandsupportstoinformthem of the Bloom Program and to lay the groundwork for increased patient-centered collaborativepractice;and,participationinBloomProgramtraining.

Eachpharmacywasalsorequiredtohaveanin-houseprofessionallibraryofessentialmentalhealthandaddictionsandpsychotropic resources, aswell asone for patients (pamphletsandother informationaboutlocalservicesandsupports)tosupportpatientmedicationeducationandnavigationofthementalhealthandaddictionssystem.

iii. Pharmacisttraining

PartoftheapplicationwasarequirementthatallleadBloomProgrampharmacistsparticipateinafull-daytrainingsessionthatconsistedofanin-depthreviewofprogrampoliciesandproceduresandseveralinteractive sessions with expert pharmacists, people with lived experience of a mental illness andaddictions,psychiatrists,andsimulatedpatient scenariosoverseveralpatient-pharmacist interactions.AnagendaofthetrainingcanbefoundinAppendixD.Pharmacistsandpharmacystaffalsohadaccesstoacomprehensivesetofreadingsandonlinevideosthroughouttheprojectperiod.Duringtheprojectperiodtwotrainingsessionswereheld.

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After the training, each Bloom Program pharmacist was expected to fully orient other pharmacists,dispensary staff, and store employees at their respective pharmacies to ensure that staffswere fullyfunctionalwiththeclinicalandproceduralexpectationsoftheProgram.

Qualityassurance

The Bloom Program built quality assurance measures into the program design to ensure patientsreceivedsafe,highqualityprogramservicesandsupports.Qualityassuranceactivitiesincludedaudits,site visits, annual reports, and bi-annual renewal applications. During the site visits, the programcoordinator checked to ensure pharmacies were complying with practices outlined in the BloomProgramPharmacyProcedureManualandfullyfunctionalwiththeclinicalandproceduralexpectations.All interactions with Bloom Program patients and health care providers had to be documented inProgressNotesineachpatient’schart.

PharmacieswerealsorequiredtosupplyacopyoftheirmostrecentNovaScotiaCollegeofPharmacists’(NSCP)audittothecoordinatoraspartofthequalityassuranceprocess.

AdiagramoutliningtheBloomProgramauditprocesscanbefound inAppendix E.Duringtheprojectperiod,eachpharmacyreceivedoneon-siteaudit.

PatientcareintheBloomProgram

AfterpharmaciesreceivedapprovaltodelivertheBloomProgramtheycouldenrollpatientsanddeliverthe program’s services and supports. This section provides details on some of the key patient careprocessesintheprogram,whichconsistof:1)enrolment,2)assessment,3)follow-up,and4)discharge(seeFigure5).

Figure5:PatientcareflowintheBloomProgram

Enrolment Initial Assessment

Early days

Follow-up assessment & management

(≥1/mo)

Weeks to months

Transfer (anytime)

Discharge Assessment

6 Months

Extension (justified)

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Eligibility,referralandenrolment

BloomProgrampatients can self-refer or be referred by another person such as a familymember, apharmacist or other health care professional, or someone from a community organization. Thepharmacisttakesthetimetoexplaintheprogramtothepatientand if there is interest,anEnrolmentForm(AppendixF)iscompleted.

Toensureequity inaccess to theprogram,all individuals livingwithinNovaScotiawithaNovaScotiahealthcardwereeligiblefortheprogram.Theprogramdidnotlimitaccessbyageoranyotherpre-setcriteria.

Inordertobeacceptedintotheprogram,thepatientmustmeettwocriteria.First,theymusthaveoneor more mental health or addictions disorder diagnosis that could be either high priority diagnoses(recommended)or‘other’diagnoses.Second,theymustidentifyoneormoremedicationmanagementissuesthattheywouldliketoworkonwhileintheBloomProgram.Alistofdiagnosesandmedicationmanagement issuecategories isprovided inTable 7.AdetaileddescriptionofBloomProgrampatientdiagnosescanbefoundinTable10,p.26.AdetaileddescriptionofthemedicationissuesidentifiedbypatientsatBloomProgramenrolmentcanbefoundinTable11,p.27.

Severalfactorswereconsideredwhenselectingdiagnosesto include.Theyare:1)theillnessresults infunctional impairment;2) the illnesshasa large impactonpersonaland family functioningandbringsabouta substantial socialandeconomiccostatapopulation level;3) the illness is commonly treatedwithandresponsivetopharmacotherapy;4)achievingoptimalpharmacotherapyoutcomesisfrequentlychallenging (e.g., non- or partial-response, adverse effects, drug interactions, withdrawal syndromesupon treatment termination); and 5) pharmacists have the knowledge and skills to support resolvingillnessandpharmacotherapyissues.

To assure that the target population of the Bloom Program (i.e., those living with a serious mentalillness) were able to access the service, pharmacists were directed to have a case mix of ≥70% ofparticipantswithhighprioritydiagnosisand≤30%withthe“other”diagnoses.Patientswithanaddictiondisorderwouldhavetohaveaconcurrentmentalhealthdisorder9andallpatientshadtohaveoneormoremedicationmanagementissuesthatweredeemedbythepharmacisttohavethepotentialtobereasonablyaddressedbyparticipatingintheprogram.

9For example, if a patientwas addicted to opiates andwas being treatedwithmethadone, theywould also have to have amental healthdiagnoses(selfidentified)inordertobeeligiblefortheBloomProgram.

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Table7:EligibilitycriterionforBloompatientenrolment

Highprioritydiagnoses: Medicationtherapyissue:

o Psychosis(e.g.,schizophrenia,unspecifiedpsychosis)o Bipolarandrelateddisorders(e.g.,bipolardisordertypes1and2)o Depressivedisorders(e.g.,majordepressivedisorder)o Anxietydisorders(e.g.,socialanxietydisorder,panicdisorder)o Obsessive-compulsive and related disorders (e.g., OCD, body

dysmorphicdisorder)o Trauma and stress related disorders (e.g., post-traumatic stress

disorder)

o Treatment optimization: Following astandard trial of recent mentalhealth/addictions pharmacotherapy, thereis non-response or partial responserequiringchangeinpharmacotherapy;

o Treatment adverse effect: Experiencing atreatment-limitingadverseeffecttocurrentmental health or addictions medication(s)requiringchangeinpharmacotherapy;

o Non-adherence:Medicationrefusalornon-adherence leading to a current or a near-recentdecompensationofmentalillnessoraddiction.

o Medicationwithdrawal:Difficulty taperingandstoppingtreatmentforamentalhealthoraddictionsprobleminastablepatient.

o Inappropriatepolytherapy:Takingmultiplemedications, including psychotropics andnon-psychotropics, that is causingfunctional impairment requiringmodifications including medicationdiscontinuation(s) on the basis of safety,redundancy,andabsenceofindication.

Otherdiagnoses:

o Feeding and eating disorders (e.g., anorexia nervosa, bulimianervosa)

o Sleep-wake disorders (e.g., insomnia disorder with episodic,persistent, or recurrent specifier (excluded is acute insomnia),narcolepsy,circadianrhythmsleep-wakedisorders)

o Personalitydisorder(e.g.,borderlinepersonalitydisorder)o Neurodevelopmental disorders (e.g., intellectual disability

disorder, Autism, attention-deficit/hyperactivity disorder, ticdisorder)

o Disruptive, impulse-control, and conduct disorders (e.g.,oppositional defiant disorder, intermittent explosive disorder,conductdisorder)Substance-related and addictive disorders (e.g., alcohol usedisorder;sedative,hypnotic,oranxiolyticusedisorder)

Assessmentandcareplanning

If the patientmeets program criterion, a one-hour assessment appointment is scheduled where thepharmacistcompletesacomprehensivemedicalhistorywiththeclient, includingdocumentationofallpatient medications (see Assessment Form, Appendix G). The patient identifies any medicationmanagement issues theywould like to see improved or resolved,with a focus onmental health andaddictionsbut includingany relevantphysicalhealthproblem(s). Thepharmacist thenworkswith thepatient to develop a care plan that is based on the client’s priorities. This initial assessmentappointment sets the stage forwhat thepatientwillworkon in theProgramwith thesupportof thepharmacist. These care plans are flexible and can be adjusted depending on progress made orchallengesencounteredthroughoutthetreatmentperiod.

At the assessment appointment, the pharmacist and patient establish a schedule of visits. Thefrequency, duration, and focusof subsequent appointments aredeterminedbypatientneedand canrangefrommonthlytobiweeklyorweekly.Itisexpectedthatasthepatientmakesprogressintheircareplan, meetings will become more infrequent. Consultations typically take place in private patient

17

consultation rooms at the pharmacy10 but they can also take place off-site (i.e. nursing homes,treatmentcenters,thepatient’sownresidence)andbytelephone.Patientsareencouragedtodropbythepharmacy,orcallthepharmacist,iftheyhaveanyquestionsorconcerns.

Patientcarefollow-up

After the initial comprehensive assessment, the patient spends his/her remaining time in the BloomProgramworkingwiththepharmacisttoaddresstheirself-identifiedmedicationmanagementissue(s).This is generally accomplished by the pharmacist communicating and collaboratingwith other healthcareproviderstoimplementanymedicationmanagementchangesrequiredandtosupportthepatienttonavigate thementalhealthandaddictions systemso that theycanmoreeasilyaccess the servicesandsupportstheyneed.Thetimeperiodforthispartoftheprogramispatientspecificbutitcanrangefromseveralweekstosixmonths.Patientswouldgenerallyseethepharmacy’sleadBloompharmacistbutwhens/hewasnotavailablepatientscouldspeakwithotherpharmacydispensarystaffwhowouldcommunicatewith thepatient’sprimaryBloomProgrampharmacist, directlyor viadocumentation inthepatient’schart.

Communicationandcollaboration

Communicationsandcollaborationwithotherhealthcareprovidersinthepatient’sself-identifiedcircleofcareisakeycomponentoftheBloomProgram.Pharmacistsareviewedaspartofapatient’sbroaderhealthcareteamthatwillhavethegreatest impacton improvingapatient’soutcomeswhentheyareeffectivelycommunicatingandconsistentlycollaboratingasneeded.

Duringtheassessmentappointment, thepatientcompletesaContactPreferencesForm (AppendixH)that listsotherpeoplethatthepharmacistcancontact.Thepharmacistmakesitclearthathe/shewillbeworkingwith thesehealth careproviders to address thepatient’ identifiedmedication issues. Keycontacts are the patient’s family physician and a psychiatrist and/or mental health and addictionscounsellor that the patient may be seeing. Ongoing communication and collaboration is expectedthroughoutthepatient’sinvolvementintheprogram.

Navigationsupport

Navigating the mental health and addictions systems can be very challenging for people living withmentalhealthandaddictionsproblems.Assuch,BloomProgrampharmacistsareexpectedtosupportpatients tonavigatethesesystemsandsometimesact inanadvocacyroleonbehalfof thepatient toresolve medication management issues. The Bloom Program pharmacist is expected to beknowledgeableaboutlocalmentalhealthandaddictionsservicesandsupports.Inadditiontoprovidinga resource library in the pharmacy with information about local services, the pharmacist is able tosuggest/recommendandpotentiallyreferthepatienttoappropriateservices.

10AllBloomProgrampharmaciesmusthaveaseparatepatientconsultationroom.

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Medicationeducation

Bloom Program patients typically take one or more psychotropic11medications to treat the mentalillness(es)theyarelivingwith.AnimportantpartoftheBloomProgramisforthepharmacisttotakethetime to educate patients about themedications they are taking in the context of addressing patient-identified medication management issues. It is expected that providing this education will increasemedication awareness and knowledge and help support the patient to take a more active role inmanagingtheirmentalillnessandaddiction(s).

Monitoringanddocumentation

Monitoring patient progress is an important part of the program’s quality assurance measures.Scheduling regular consultations for the six-month program period allows for regular monitoring ofmedication changes outcomes and patient health generally. Pharmacists document each patientencounterinformalProgressNotes(Appendix I),identifyingthepurposeofthevisitandtheoutcome.ProgressNotes includedocumentationofanyattempts tocontact thepatient,knowledgeacquisition,paperworkand informationand resourcepreparation,andcontactswithothercareproviders suchasfamilyphysiciansandpsychiatrists,andtheoutcomesthereof.

Discharge

Patientscanstay in theBloomProgram forup to sixmonthatwhichpoint theywillbeautomaticallydischarged.This timeperiodwas felt tobe reasonable formostmedicationmanagement issues tobeimprovedorresolved.ThepharmacistcompletesaDischargeForm(Appendix J)and identifiespatientprogramoutcomesandanysignificanteventsduringenrolmentaredocumented.Ifthepatientrequestsmore time and the pharmacist feels this will help resolve the medication management issue(s), anapplicationforsix-monthextensioncanbesubmittedtotheBloomProgrammanagement.

11Relatedtoaperson’smentalhealth.

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EvaluationoftheBloomProgram

Monitoring and evaluation of the Bloom Program demonstration project was viewed as critical tosuccessful implementation, quality assurance, and most importantly, determination of whether theprogramwas feasible to operate in theNova Scotia context. This report presents the findings for anoutcomeevaluationoftheprogram.Italsopresentsfeedbackfrompatients,physiciansandpharmacistsonhowtheprogramcouldbeimproved.Shouldtheprogrambeexpanded,aprocessevaluationcanbecompletedondatathathasalreadybeencollected.12

AnEvaluationAdvisoryCommitteewasformedinthefallof2015toprovidedirectionfortheevaluationframeworkandtoreviewthelogicmodelanddatacollectiontools(surveysandinterviewguides).TheCommitteeprovided feedbackon thedraftevaluation report.A listofmembernamesandassociatedorganizationscanbefoundinAppendixA.

Evaluationpurpose

BecausetheBloomProgramisademonstrationproject,thisevaluationisanopportunitytolearnabouthowcommunitypharmaciescanplayanenhancedrole insupportingpeople livingwithmentalhealthandaddictionsproblemsinthisprovince.

Theprimarypurposeof thisevaluation,however, is toprovide theNovaScotiaDepartmentofHealthandWellness and theNova ScotiaHealth Authoritywith information about the impact of the BloomProgramthatwillhelpthemdeterminewhetheritshouldbeexpandedandintegratedintotheexistingmentalhealthandaddictionssystem.Thisevaluationhasacompaniondocumentthatprovidesfinancialanalysisoftheprogramthatwillhelpinthisdecision-making.

Programlogicmodel

A logic model is a useful planning tool that visually depicts a program’s theory of change. Severaliterations of the Bloom Program logic model were developed as the program evolved. Appendix Kdepicts the Bloom Program Logic Model that was approved by the Steering Committee during theprogram’simplementationstage.AppendixLprovidesarevisedpatientoutcomelogicmodelthatwasdevelopedpriortodatacollectionandanalysisforthisoutcomeevaluation.

Programoutcomesmeasured

Asdepictedintherevisedlogicmodel,theBloomProgramidentifiedexpectedprogramoutcomesthatfocusedonthreestakeholders:programparticipants(peoplelivingwithmentalhealthand/oraddictionsproblems), pharmacists, and the Nova Scotia mental health and addictions system (system level

12Outcomeevaluations should ideally followprocessevaluations that identifyareas forprogram improvements.Once these improvements aremade, programdecision-makers and staff feel confident that activities are beingimplementedasintendedandanoutcomeevaluationcandetermineiftheprogram’stheoryofchangeiscorrect.Conductingbothtypesofevaluations,however,israrelyfeasibleinshort-termdemonstrationprojectsthatincludeanimplementationperiod.

20

outcomes). This evaluation focused primarily on patient outcomes, which are linked to system-leveloutcomes.

The short-term outcomesmeasured in this evaluation were expected to occur during the patient’senrolmentintheprogram.Theyareasfollows:

1. Patientshave:

A. increasedaccesstomentalhealthandaddictionsservicesandsupportsintheircommunityB. increasedaccesstopharmacistsC. increasedknowledgeandawarenessofmedicationsandhealthD. increasedsupporttonavigatethehealthsystemE. increasedawarenessofcommunityresources

2. Medicationandotherrelatedhealthissuesareidentifiedandactedupon.

3. Pharmacistsandphysiciansarecommunicatingaboutpatientcare.

The intermediateoutcomesmeasured in thisevaluationwereexpected toward theendofapatient’sparticipationintheprogramandatprogramcompletion.

1. Patients are able to access available services and supports important for their care andwellbeing.

2. Healthandmedicationissuesarebettermanagedand/orresolved.3. Careprovidersarecollaboratingtomeetpatient’sneeds.4. Patientsaremoreawareofthepharmacistroleinmentalhealthandaddictions.

Methodology

TheBloomProgramevaluationusedamixed-methodsapproachtomeasureoutcomes.Qualitativeandquantitativedatacollectionmethodswereusedtogather information fromtheprimarydatasources:patients, pharmacists and pharmacy staff, and physicians (family physicians and psychiatrists). Asummaryofthemethods,sourcesandsamplesizesisprovidedinTable8.

Administrativedata

Patientcharts

Datacollected inpatientcharts, includingProgressNotes,wasabstractedandanalyzedfordescriptivestatistics (including frequencies andmeans) by the program leads and Dalhousie University studentsusingSPSSandMicrosoftOfficeExcel.

APrivacyImpactAssessmentwascompletedfortheNSDepartmentofHealthandWellnesstoensuredatacollectedwasabstractedsecurelyandhandledinasafeandconscientiousmanner.

Programdata

Programdatawascollectedandanalyzedonanongoingbasisbytheprogramcoordinatorsuchasnumberofparticipatingpharmacies,datarelatedtotraining,outreachactivities,etc.

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Table8:Evaluationdatacollectionmethods,sources,andsamplesizes

Data collectionmethod

Source Samplesize(n) Timeperiod

Administrative data(patientcharts)

Patients 201(totalpatientcharts) Ongoing

46(dischargedpatientscharts)

May-August2016

Administrative data(programdata)

Pharmacies 23 Ongoing

Surveys Patients 36 March–June2016

Pharmacystaff(pharmacists&pharmacytechniciansandassistants)

25(7non-pharmacists) March–June2016

Physicians 11 March–June2016

Communityorganizations 28 June2016

Key informantinterviews

Patients 10 May-June2016

Pharmacists 21(representing20pharmacies)

February2016

Physicians 10 June2016

Surveys

All Bloom Program patients, pharmacists and pharmacy staff, physicians who had a Bloom Programpatient,andcommunityorganizationswereinvitedtocompleteabriefprogramsurveythatconsistedofclosedandopen-endedquestions.Patientswerecontactedandinvitedtocompleteeitheranon-lineorpapersurvey.Pharmacistsandpharmacystaffweresentalinktothesurvey.DoctorsNovaScotiaalsocirculatedalinktothesurveythroughtheirmemberlistserveandontheirWebsite.LinkstoallsurveyswerealsopostedontheBloomProgramwebsite.

TheEvaluationAdvisoryCommitteereviewedthesurveysbeforetheywerefinalized.

Descriptive statistics (including frequenciesandmeans)were calculatedandanalyzedby theprogramleadsandDalhousieUniversitystudentsusingMicrosoftOfficeExcel.

Surveyrespondents(patients,pharmacistsandphysicians)wereinvitedinthesurveytoprovidecontactinformationiftheywantedtoparticipateinafollow-upinterview.

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Interviews

AllBloomProgrampatients,pharmacistsandphysicianswhohadBloomProgrampatients,wereinvitedto participate in a semi-structured interview. For physicians, a list of names of family physicians andpsychiatrists who had Bloom Program patients was provided to the evaluator by Bloom Programpharmacists.Allphysiciansonthislist(n=26)werecontactedbytelephoneand/oremailandinvitedtoparticipate.Severalphysiciansrespondedbutwerenotavailableforaninterview.

Physicianinterviewrequestsandcompletions

Contactedandinvited 26

Completedinterviews 10

Notimeforaninterview 2

Supportsprogrambutnotimeforaninterview 1

NotawareoftheBloomProgram 4

Noresponsetointerviewrequest 9

All leadBloompharmacistswere invited toparticipate in an interview. In some cases thepharmacistwasalsotheownerofthepharmacy.

Participationinallinterviewswasvoluntaryandallparticipantswereaskedtoprovideverbalconsenttoparticipate and for the interview to be audio-recorded and transcribed for analysis. Most interviewswere conducted by telephone and lasted between 30-60 minutes for patients and pharmacists andbetween10-30minutesforphysicians.Patientswereoffered$40.00ashonorariaandphysicianswereoffered$100.00.

InterviewguideswerereviewedbytheEvaluationAdvisoryCommitteeandinterviewswereconductedby the Bloom Program evaluators and the program coordinator. Data was analyzed by the programevaluatorsandtheprogramleadsusingtheNVivoqualitativedataanalysissoftware.Alltranscriptswerecoded using an evolutionary coding structure in NVivo. High level coding nodes were specified tocorrespond to the intendedoutcomesof theBloomProgram.Sub-themeswithineachoutcomenodeemerged as the data was analyzed and nodes were created as necessary. Qualitative survey datacorrespondingtotheoutcomeswereincludedintheinterviewdataforanalysis.

Limitations

ImplementationofarealworldcomplexinterventionsuchastheBloomPrograminanenvironmentinwhichmultipleand substantial changesareunderway createa challenge foranoutcomesevaluation.Ourmixedmodel approach relies on evaluatingmultiple outcomes, primarily short and intermediateterm, triangulatingourdatawherepossible toassess thevalidityof the findings.Thesamplesizeandlengthofthisdemonstrationprojectarenotsufficientforaformal,traditionaleconomicevaluation.Toensurethattheprogramwaspracticalandacceptabletopharmacistsandpatientsaflexibleevaluationframeworkwas developed.Amore rigorous and less flexible intervention research studywasneither

23

feasible,practical,noraffordable.Suchstudiestypicallyfailtoidentifywhatisimportantintermsofthefidelityofaninterventionwhentheinterventionitselfiscomplex.

Expectations

AspecificchallengeofevaluatingtheimpactoftheBloomProgramistomeasureitsimpactonpeoplewhoareno longer in theprogramorwhowerenever in theprogram.Auniqueaspectof theBloomProgram is thatpatientscontinuetohaveaccess tocare immediatelyafterbeingdischargedfromtheprogramby the same care providers – the patient’s pharmacy team; continuity is therefore not lost,whichisdifferentfromsomeothermentalhealthandaddictionsservices.

Patientsareexpectedtohaveanimprovedpharmacist-patientrelationshipaftertheyleavetheprogramcompared to the relationship before entering the program. The pharmacist is expected to be moreeffectiveinsupportingthatpatientinaccessingcare,identifyingandaddressinghealthandmedicationissues,collaboratingwithothermembersofthepatient’shealthteam,andinsupportingefficienciesinthehealthsystem.

It isalsoexpectedthat theprogramwillbenefitpeoplewithmentalhealthandaddictions issueswhoaccess pharmacies that offer the Bloom Program but who are not enrolled in the program. Byparticipating in the Bloom Program, pharmacists will be more knowledgeable of local resources,supports, and services as well asmedication and health issues relevant to people livingwithmentalhealth and addictions problems generally. Figure 6 represents the three patient groups that areexpectedtobenefitfromapharmacyofferingtheBloomProgram.

Figure6:MentalhealthandaddictionspatientgroupsexpectedtobenefitfromtheBloomProgram

Currentlyenrolledpaoents

Formerlyenrolledpaoents

Neverenrolledpaoentswithmentalhealthandaddicoonsproblems

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Evaluationfindings

DescriptionofBloomProgrampharmacies

Atotalof23pharmaciesparticipated in theBloomProgramdemonstrationproject representing ruraland urban communities located throughout Nova Scotia. Table 9 provides information about theparticipatingpharmacies.Figure7showswherethepharmaciesarelocatedintheprovinceandBoxAindicateswhichlocationswereclassifiedasurbanandrural.

Table9:DescriptionofpharmaciesapprovedtooffertheBloomProgram

NovaScotiahealthmanagementzones Approved Active

WesternNorthernEasternCentral

75610

5468

Total 28 23

Typeofpharmacy*

IndependentCorporate/franchise

235

203

Locationofpharmacy

RuralUrban

1612

1310

*Thefollowingbannerswereclassifiedasindependentlyownedpharmacies:Compass,Guardian,theMedicineShoppe,Pharmachoice,andPharmasave.ShoppersDrugMart,Sobeys/Lawtons,andTargetpharmacieswereclassifiedascorporate/franchisepharmacies.

Figure7:MapofBloomProgrampharmaciesinNovaScotia

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BoxA:BloomProgrampharmacylocations

Ruralcommunities(13)AmherstAntigonishAylesford

BridgetownCheticampDigby

EnfieldKentvilleMahoneBay

PortHawkesburySt.PetersStellartonWindsor

Urbancommunities(10)DartmouthHalifax(5)

NorthSydneySydney

Truro(2)

Patientdemographics

AsofJune30,2016,221patientshadenrolledintheBloomProgram.ThefirstpatientwasenrolledonSeptember 20, 2014. Pharmacistswere asked not to enrol any patient after June 30, 2016.Table 10providesdemographic informationabouttheBloomProgrampatients. Table11andFigure8providedetailsonthehealthstatusofBloomProgrampatientsupontheirenrolmentintheprogram.

For patientswith oneormore follow-up visits (n=182), themajoritywere female (62.6%), livingwithfamilyand friends (64.8%),andeithermarried/common-law (41.2%)or single (38.5).Therewasamixbetween unemployed (47.8%) and employed (37.5%) as well as across education levels. Most werecoveredbypublic(47.8%)orprivate(38.5%)insurance.

BloomProgrampatients closelymirrored the characteristics of themental health population inNovaScotia. Anxiety (69%), depression (63%), and sleep disorders (36%) were the most frequent patient-identifiedmentalhealthproblems,followedbysubstanceusedisorders(16%),PTSD(14%),andbipolardisorder (11%). The most commonly used medications were antidepressants (72%), benzodiazepinesandrelateddrugs(53%),andantipsychotics(29%);68%ofpatientsweretakingmultiplepsychotropics.Physical health problems (e.g. pain& neurological disorders: 38%; cardiovascular disease: 28%)wereprevalent: 71% of the participants were taking multiple physical health medications. Overall, BloomProgrampatientsweretakinganaverageof5.5prescribedmedications(range0to24).Useofnicotine(39%),alcohol(38%),andmarijuana(18%)werecommon.Mostpatients(81%)enrolledintheprogramto work with their pharmacist to optimize their medication regimen in order to achieve improvedsymptomaticandfunctionalhealthoutcomes.Inaddition,24%identifiedmanagingadverseeffectsand13%identifiedseekinghelpwithdiscontinuingmedicationasreasonsforenrollment.

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Table10:DemographicsofBloomProgrampatients

Allpatients(n=201)

Patientswith≥1follow-upvisit(n=182)

Mean SD Mean SDAge(mean,SD) 48.1 15.7 47.9 16.1 n % n %Sex-Female 120 59.7 114 62.6-Male 81 40.3 68 37.4Livingsituation

Family/friends 131 65.2 118 64.8Alone 47 23.4 44 24.2Grouphome 7 3.5 7 3.8Other 4 2.0 4 2.2Unknown 12 6.0 9 4.9

Status Married/commonlaw 83 41.3 75 41.2Single 75 37.3 70 38.5Separated/divorced 25 12.4 22 12.1Unknown 18 9.0 15 8.2

Dependents Yes 72 35.8 64 35.2

Occupationalstatus Employed 71 35.3 68 37.5Unemployed 99 49.3 87 47.8School 11 5.5 10 5.5Unknown 20 10.0 17 9.3

Education Lessthanhighschool 27 13.4 24 13.2Highschool 46 22.9 39 21.4College/university 65 32.3 61 33.5Unknown 63 31.3 58 31.9

Medicationcoverage Publicinsurance 96 47.8 87 47.8Privateinsurance 78 38.8 70 38.5Cash 20 10.0 18 9.9Unknown 7 3.5 7 3.8

Physiciancare Familyphysician 188 93.5 173 95.1Psychiatrist 66 32.8 63 34.6None 9 4.5 6 3.3

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Table11:HealthstatusatenrolmentintoBloomProgram

Allpatients(n=201)

Patientswith≥1 follow-upvisit(n=182)

Mean SD Mean SD

Numberofstatedhealthproblems 2.7 1.4 2.7 1.4

n % n %

Participants with mental health andaddictionsproblems

201 100% 182 100%

Psychoticdisorder 13 6.5 11 6.0

Bipolardisorder 23 11.4 20 11.0

Depressivedisorder 126 62.7 112 61.5

Anxietydisorder 139 69.2 126 69.2

Obsessivecompulsivedisorder 15 7.5 15 8.2

Post-traumaticstressdisorder 29 14.4 27 14.8

Eatingdisorder 8 4.0 8 4.4

Insomniaorothersleepdisorder 72 35.8 64 35.2

Personalitydisorder 11 5.5 11 6.0

ADHD 13 6.5 13 7.1

Disruptivebehaviourdisorder 6 3.0 6 3.3

Substanceusedisorder 32 15.9 29 15.9

Number of mental health and addictionsproblems

487 442

Participantswithphysicalhealthproblems 113 56.2 104 57.1

Painandneurologicaldisorders 77 38.3 72 39.6

Cardiovasculardisease 56 27.9 53 29.1

Gastrointestinaldisorders 29 14.4 22 12.1

Endocrinedisorders 27 13.4 25 13.7

Respiratorydisorders 21 10.4 18 9.9

Other 47 23.4 44 24.2

Numberofphysicalhealthproblems 257 234

Substanceuse

Nicotine 78 38.8 66 36.3

Alcohol 75 37.3 68 37.4

Marijuana 36 17.9 30 16.5

Opiates 23 11.4 19 10.4

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Figure8:Mentalandphysicalhealthproblemsatenrolment

TheBloomProgramaimedtoidentifypeoplelivingwithmentalillnessandaddictionswhocoulddirectlybenefit from the care provided by community pharmacists working collaboratively with patients andmembers of their health care teams. Qualifying diagnoses for the programwere identified based ontheirprevalenceand,mostimportantly,theirassociationwithpsychotropicpharmacotherapyforwhichtreatmentfailure,adverseeffects,misinformation,andnon-adherencearecommonissues.

It isdifficulttodeterminewithcertaintyhowwellthesampleofpatientsenteringtheBloomProgrammatch theprevalenceof those inneedof this levelof service.We found thatanxietyanddepressionwere themost prevalent diagnoses (63-69%)with insomnia also common (36%). Less frequentweresubstanceusedisorder(16%),PTSD(14%),andbipolardisorder(11%).Theprevalenceoftheremainingdiagnoseswaseachlessthan10%inthecohort.

Intheirworkmeasuringtheratesoftreatedpsychiatricdisorders,Kiselyandcolleaguesdeterminedthat~15.7%ofthepopulationofNovaScotiareceivementalhealthcareeachyearbasedonphysicianbillingcodes.13Similar toour findings, 63% (9.9%)of this groupwasdiagnosedwithdepressionor anxiety.14Theprevalenceratesofcareprovidedbyphysiciansforpeoplewithotherdiagnosesarenotavailable.

13KiselyS,LinE,LesageA,GilbertC,SmithM,CampbellLA,VasiliadisHM.Useofadministrativedataforthesurveillanceofmentaldisordersin5provinces.CanJPsychiatry.2009Aug;54(8):571-5.PMID:1972601014KiselyS,LinE,GilbertC,SmithM,CampbellLA,VasiliadisHM.Useofadministrativedataforthesurveillanceofmoodandanxietydisorders.AustNZJPsychiatry.2009Dec;43(12):1118-25.doi:10.3109/00048670903279838.

69%

63%

56%

36%

16% 14%11%

8% 7% 7% 6% 4% 3%

38%28%

23%14% 13% 10%

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Table12:MedicationissuesatBloomProgramenrolment

Allpatients(n=201)

Patientswith≥1follow-upvisit(n=182)

n % n %

Medicationissues

Treatmentoptimization 162 80.6 148 81.3

Adverseeffects 49 24.4 44 24.2

Non-adherence 22 10.9 15 8.2

Medicationwithdrawal 27 13.4 23 12.6

Inappropriatepolytherapy 12 6.0 9 4.9

Medications

Antidepressants 145 72.1 130 71.4

Benzodiazepines-Zdrugs 107 53.2 98 53.8

Antipsychotics 58 28.9 50 27.5

Moodstabilizers 21 10.4 19 10.4

Psychostimulants 12 6.0 12 6.6

OtherPsychotropics 13 6.5 12 6.6

Opioids 24 11.9 23 12.6

Opioidreplacementtherapy 15 7.5 14 7.7

Multiplepsychotropicmedications 136 67.7 122 67

Nopsychotropicmedications 9 4.5 7 3.8

≥1physicalhealthmedications 142 70.6 130 71.4

Mean SD Mean SD

Numberofcurrentmedications 5.4 4.0 5.5 4.1

Rangeofcurrentmedications 0to24 0to24

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Figure9:Medicationsatenrolment

Themajorityofpatientswereusingmultiplepsychotropicandmultiplephysicalhealthmedicationsatenrolment.SeeTable12(p.29)andFigure9.Theaveragepatientwastakingmorethan5medications.Antidepressants, sedative-hypnotics, and antipsychotics were the most commonly used medications,with opioids, mood stabilizers and psychostimulants also used by patients entering the Program.Additionally,morethan70%wereusingmultiplemedicationsforvariousphysicalhealthproblems.Notunexpectedly, patients entering the programwere takingmultiplemedications and not achieving theintendedbenefits.

Programdata

ReferralSources

Referral to the Bloom Program was open to anyone. As seen in Figure 10, the majority of patientsenrolled in the programwere informed of and referred to the programby a pharmacist offering theprogram at their pharmacy. Family physicians and psychiatrists collectively referred one in every sixpeoplethatenrolledintheprogram.Familyandfriendsandmentalhealthandaddictionsorganizationsreferredasmallernumberofpatientstotheprogram.Itisexpectedthatthereferralpatternwillevolveastheprogrambecomesmoreestablishedandwellknowninacommunity

72%

53%

29%

12% 10% 8% 7% 6%

68% 71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

31

Figure10:SourceofreferraltotheBloomProgram

Programcompletion

Thechartdataanalysisestimatedtheaveragetimeintheprogramforthosepatientswhowereformallydischargedusingtheprogram’sdischarge form(n=46).Mediandurationofenrolment in theprogram,fromenrolmenttodischargedate,wassixmonths(183days,IQR:155,247).Another11patientswereassumeddischargedatthetimeofchartreviewbasedonadocumentedplantodischargethepatientfollowedbyatleastthreemonthsofinactivity.Justbelow30%ofpatientswerelosttofollow-up,earlyor late,duringtheirparticipation intheprogram.Oneelderlymedicallyunwellpatient (cardiovasculardisease, diabetes, hypertension, COPD, underweight, depression, anxiety, polypharmacy) died shortlyafterenrollingintheprogram.Afullaccountofpatientdispositionbasedonthe201chartsreviewedisprovidedinTable13.

Bloompharmacist66.1%

Otherpharmacist1.1%

Familyphysician12.6%

Psychiatrist4.6%

Family8.0%

Self3.4%

MH/AOrg1.7%

Other2.3%

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Table13:Dispositionofpatientsbasedonchartreview*

Disposition Numberofpatients(%)

Stillinprogram 84(41.8%)

Dischargedusingdischargeform 46(22.9%)

Assumed discharged (documented discharge plan with >3 months ofinactivity)

11(5.5%)

Earlylosstofollow-up(<3monthsinprogram) 37(18.4%)

Late loss to follow-up (>3 months in program without documentedactivityorplanneddischarge)

22(11%)

Deceased 1(0.5%)

Total 201(100%)*Dateoffirstpatientenrolment:20-Sep-2014.Dateoflastpatientenrolment08-Mar-2016

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Outcome1:AccessandNavigation

Short-termoutcomes

- Patientshaveincreasedaccesstopharmacists- Patientshave increasedaccess tomentalhealthandaddictions services and supports in their

community- Patientshaveincreasedsupporttonavigatethehealthsystem- Patientsaremoreawareofcommunityresources

Intermediateoutcomes

- Patients are able to access available supports and services important for their wellbeing andcare

Evaluationquestions

- To what extent did Bloom Program patients have increased access to mental health andaddictionscareandsupportsinthecommunityasaresultofparticipatingintheprogram?

- TowhatextentdidtheBloomProgramsupportpatientstonavigatethehealthsystemandwasaccesstotheseserviceslinkedtoimprovedwellbeingandcare?

Keyfindings

• Overall, the Bloom Program increased patient access to pharmacy-based, medication-focusedmentalhealthandaddictionsservicesandsupports.Thiswasachievedasaresultofseveralfactorsrelatedtothecurrentmentalhealthandaddictionssystemandpatientneeds.

• BloomProgrampatientshadincreasedaccesstopharmacistswho,asaresultoftheprogram,wereabletodedicatemoretimetohelpingpatientsaddressmedicationmanagementissues.Supportwasprovidedbyaccessingpharmaciststhroughscheduledpatient/pharmacistmeetings(in-personorviatelephone)aswellasinformaldrop-insupport.

• The Bloom Program helped address some of the current gaps that exist in mental health andaddictionscarebyprovidingpatientswithservicesandsupportswhiletheywerewaitingforotherservices,andbyofferingtheprogramoutsideoftypicalservicehours(i.e.eveningsandweekends).

• The Bloom Program also increased the range of mental health and addictions care options forpatientswhowerenotaccessingotherservicesandsupports.

• Patients identified and expressed their appreciation for the general psychological and emotionalsupportprovidedtothembytheirpharmacist.Oftenthiswasinthecontextofthepatientnotbeingable to access local mental health and addictions care in their community, particularly in ruralcommunities.Manyparticipantssaidthattheyvaluedthisaspectoftheprogrammost.

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• PharmacistshelpedBloomProgrampatientsnavigatethehealthsystemgenerallyandthisactivityhelped them access othermental health, addictions and general health care. Through theBloomProgram, patients accessed a range of supports that included counseling, peer supports, primaryhealthcareproviders,supportforchronicdiseasemanagementandspecialists.

• Pharmacists also provided navigation supports to other people in the community who were notenrolledintheBloomProgram.

Analysis

TheBloomProgramevaluationfoundthatpeoplelivingwithmentalhealthandaddictionsproblemsdidexperience increasedaccesstomentalhealthandaddictionsservicesandsupportswhiletheywere inthe program. This was achieved in several ways. Patients had increased access to a Bloom Programpharmacistwithenhanced training inmentalhealthandaddictionswhoprovided individually-tailoredmedicationmanagementsupport(theoutcomesofwhichareoutlined inthenextsection,MedicationManagement). Insomecommunities,accesstotheBloomProgrampharmacistprovidedpatientswithan additional resource or treatment option,while in other communities, primarily rural, the programaddressedand/orbridgedagapinlocalmentalhealthandaddictionsresources.

The evaluation also found that the Bloom Program was able to facilitate increase access to mentalhealthandaddictionsresourcesbecauseofitsnavigationalsupportcomponent.Inadditiontoworkingwith patients and other health care providers to address medication management issues, thepharmacists helped patients navigate and access the mental health and addictions and health caresystems generally. In some cases this included facilitatingpatient referrals to primary and specializedcare and by expeditiously connecting patients with the appropriate level of care through a triageprocess.

Thisnextsectionpresentsthedataanalysistosupportthesefindings.

IncreasedAccesstoBloomProgramPharmacists

OneofthemainstructuralfeaturesoftheBloomProgramwasprovidingpatientswiththeopportunityto regularly meet one-on-one with a pharmacist, as well as providing access on-demand, aftercompleting the initial assessment. Patients were informed through the enrolment process that thedefault duration of the program was six months during which they were to work closely with theirpharmacist and other members of their health care team to identify, prioritize, and manage theirmedication and related health concerns. They were informed that the pharmacy was being paid toprovidethisservice,therebyentitlingthepatienttoanenhancedlevelofcareandsupport.

Chartreview

AreviewofthechartdatashowedthatBloomProgrampatientshadsubstantialaccesstoandtimewiththeirpharmacistsandthatthiswassustainedwhileintheprogram.

First, patient follow-throughwith the programwas high: 182 (90.5%) of patients returned after theirinitialassessmentforoneormorefollow-upvisits(range:1to43)withtheirpharmacist.Forallpatientsenrolled,themediannumberofvisitswas5(IQR:3,9).Excludingthegroupwhodidnotreturnforany

35

visits (9.5%), themediannumberof visitswas 6 (IQR: 3,9),with twopatients having 41 and43 visitsrecorded,respectively.

Duringtheenrolmentandinitialassessment,themediantimeestimatedtocompletetheenrolmentandinitialassessmentprocesswas50minutes(IQR:35,70).Figure11showsthedistributionofthenumberofvisitsforallpatientswhoreturnedaftertheassessmentforoneormorevisits.Themediandurationofvisitswas15-20minutes foreachof the firstnine follow-upvisits.Forvisits10-17 themedianvisitduration was 10-15minutes. There were too few patients (n=7) withmore than 17 visits to reliablyestimatevisitduration.

Figure11:Distributionofthenumberoffollow-upvisitsbetweenpatientsandpharmacists

Thepatternofaccessvariedamongpatients,fittingtheprogram’sprincipleofpatient-centredcare.Asanticipated, the intensityofcarewashighestearlyon in theprogram,withmore frequentand longervisits,andgraduallydeclineasthepatient’stimeintheprogramprogressed.Figure12showsthatthemajorityof interactionswithpatientswere20minutesor less,but thatasubstantialproportionweremuchlonger.Anotableminorityofpatientsexperiencedmeetingswiththeirpharmacistof60minutesor longer, evenafterbeing in theprogram for threemonthsor longer.Alsoobservablebasedon thecolourcodingofthevisitsinFigure12isthatsomepatientshadmorethan10visitswithintwotothreemonthsofparticipatingintheprogram.Basedoninterviewdata,thiscouldbeattributedtothepatientswhoaccessedtheprogramforsocialsupport.15

15Social support:thecomponentofthepharmacist-patientinteractioninwhichthepharmacistprovidessocialsupporttothepatientthatisnotspecifictotheirdrugtherapy.Socialsupportreferstothevarioustypesofsupport(i.e.,assistance/help)thatpeoplereceivefromothersandisgenerallyclassifiedintothreemajorcategories:emotional,instrumental,andinformationalsupport.Thisincludeslisteningtopatients’concerns and distress, working to build rapport and trust, supporting self-management, providing encouragement and positive feedback,promotionofhealthybehaviours,decisions,andactions,andpromotingself-efficacy.See:BungayKM,AdlerDA,RogersWH,etal.Descriptionofaclinicalpharmacistinterventionadministeredtoprimarycarepatientswithdepression.GenHospPsychiatry.2004May-Jun;26(3):210-8.

15.4%

19.8%

22.5%20.9%

12.6%

8.8%

1-2 3-4 5-6 7-9 10-15 >15

Numberofpaoentfollow-upvisitswithpharmacists

36

Figure12:Frequencyanddurationofmeetingsbetweenpatientsandpharmacists

0

20

40

60

80

100

120

0 50 100 150 200 250 300 350 400 450

Visitd

ura0

on(m

in)

Daysinprogram

Visit1

Visit2

Visit3

Visit4

Visit5

Visit6

Visit7

Visit8

Visit9

Visit10

Visit11

Visit12

Visit13

Visit14

Visit15

Visit16

Visit17

Visit18

Visit19

Visit20

37

Finally,thechartdataanalysisrevealedthatofthetotaldocumented1233patient-caremeetingsthatoccurredupuntildatacollectionforthechartreview,therewereanestimated1687actionstakenbypharmacistsinthecareandsupportoftheBloomProgrampatients.Thetypesanddistributionoftheseactions isshown inFigure13.Theseactionsare linkedtotheprogram’scomponentsandtheywillbediscussedthroughoutthisreportingreaterdetail.

Figure13:Distributionofpurposesoffollow-upvisitsbetweenpatientsandpharmacists

Interviewdataanalysis

The interviews with patients and pharmacists confirmed that patients had increased access topharmacistsbyparticipatingintheBloomProgram.ManyBloomProgrampatientssaidthatpriortotheprogramthey interactedwith theirpharmacistsmainly in thecontextofpickingup theirmedications.Theresponsefromthepatientbelowistypicalofhowmanydescribedtheseinteractions:

Patient [Before] therewasn'tmuch interaction, right? Like I've said, youknow, just kindofgopickupyourmeds,say‘thankyou’,goonmywaykindofthing.Butnowit'slike,‘Howare you feeling?’ You know, ‘how are you?’ They seem that they're concerned andthey'reinterestedinhowI'mdoingmorethanbefore.

AsaBloomparticipant,patientshadscheduled,private,confidentialtimewithapharmacisttofocusonmedications and other psychosocial issues related to their personalmental health and/or addictions.BloompharmacistssaidthatnotonlydidBloomProgrampatientsreceivemoreoftheirtimethannon-BloomProgrampatients,theyalsorecognizedthattheywereentitledtomoretimeandweregenerallyinterestedinaccessingit.PharmacistssaidthatBloomProgrampatientsfelt liketheywerea‘priority’,weremore‘privileged’,andthattheywerebeing‘takenseriously’becausetheyweregiventime.

Patientshadgreateraccesstopharmacistsbecausethepharmacistsmadethemselvesasaccessibleaspossible.Pharmacistssaidthattheyfeltthatitwasimportantforpatientstofeelthattheycouldreachout to them at any time and they offered patients different options on how meetings could be

NavigaOon15%

Triage6%

MedicaOonmanagement

51%

CollaboraOon12%

EducaOon17%

38

conductedandwereflexibleandabletoaccommodatetheirpatients’schedulesandneedsforthemostpart.

Pharmacists Oneofmyindividualswaslike,‘WellIdon'tdrive’,like,youknow,‘Ican'tcomein.’AndIsaid,‘Well,ifyoucan'tcomeinwecandoitoverthephone,wecandowhatever.Icouldgo to you.We can dowhatever you need to do to get you healthy.’ So I think, to behonest,it'smoreaboutourcommitmenttothatpersonthatmakesabigdifference.

We'reincontactonamoreregularbasis,thatwouldbethebestwayofputtingit.Weareat leastmeetingonceamonth, plus phone calls, and thephone calls areactuallycomingfromboththepharmacyandthepatient’sendsoit'satwo-waystreet

ManypatientsindicatedthattheyweretoldbytheBloomPharmacistthattheywouldmakethemselvesaccessibletopatients.Patientssaidthiswas importanttothemandtheyappreciatedtheeasyaccess.For some, easy access was particularly important because they didn’t feel comfortable going out inpublic.

Patients WhenIwantedtoseeheritwasbasicallymychoicetoseeher.ShewouldtellmewhattimeshewasavailableandIwouldgoseeherfirstifIfeltlikeIhadtoseeherinsteadofjusttalkingtoheronthephone.

Ihaveatherapist,Ihaveapsychiatrist,andIseemydoctor,butit'slike,youknow,theaccesstotalktothem(pharmacist)isaloteasierthangettingintoseeatherapist,youknowwhatImean?Like,Icanjustwalkinonedayandjustasktotalktooneofthemifneedbe.Ididn’treallyhavethat.

Basedonthechartreview,themajority(68%)ofpharmacist-patientinteractionswereconductedatthepharmacy in private meeting rooms where confidentiality was protected; 28% were conducted bytelephone;and,4%occurredoutsideofthepharmacy,includingatnursinghomesandpatients’homes(seeFigure14).

Figure14:Howpharmacist-patientinteractionswereconducted(n=182)

Pharmacy68%

Telephone28%

Other4%

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Inmostcasesthe increasedaccesswasprimarilytothe leadBloompharmacist,whompatientswouldspecifically seekout,but somepatientsappeared toalso recognize that theywereaccessingaBloompharmacyand,assuch,allstaffhadgreaterawarenessandknowledgeofmentalhealthandaddictionsissues.BloomProgrampatientshadaccesstothefullcomplementofpharmacystaffwhowereawareoftheprogram’sobjectivesandwhowereinvolvedindeliveringtheprogram.

Patient Idon'tusuallyopenuptoalotofpeoplesoIdidwanttolimitittojustoneperson,butsort of a change came when I was in the Bloom Program. All the other people whoworked behind the counter, everybody seemed to know who was with the BloomProgramandwhowasn't.AndwhenIwouldcallforarefillorcallwithaquestiontheywerevery,veryhelpful,and,youknow,theyknewthatIwastryingtolearnthisprogramand routine and if [pharmacist name]wasn't here, they stepped in. … I did notice adifferencewiththeotherpharmaciststhewayIinteractedwiththem.

IncreasedAccesswithExtendedHoursofOperation

BloomProgramparticipantshad increasedaccess tomentalhealthandaddictionsservicesdueto theextended hours of pharmacies. A typicalNova Scotia pharmacy, even in rural communities, generallyoperatesuntil9p.m.duringweekdaysandisopenonSaturdays;somearealsoopenonSunday.BloomProgrampatientswereoftenabletoscheduleappointmentsduringextendedhoursandencouragedtodropbyandcalliftheyhadquestions.SomeleadBloompharmacistssaidtheytriedtoscheduleBloompatientappointmentswhentherewasscheduledpharmacistoverlapandduringquietertimessuchaseveningsandweekends.

Intheinterviews,theextendedhoursofpharmacyoperationwasrecognizedbypatients,physiciansandpharmacists as a factor that contributes to increased access tomental health and addictions servicesandsupports.Patientsandphysiciansappearedtoappreciatethisintermsofincreasedaccesstocare.

Patient They are there like Monday to Saturday. Like, they're available a lot more thancallingtogetanappointmenttogoinandseesomebody,right?

Physicians They are an easy resource and they are sometimesmore accessible, especially onweekends.So firstand foremost I suggest thatpatients contact them ifoutsideofofficehours.

[The Bloom Program] bringsmanagement of an addiction to the community andgivespatientstheabilitytocontactforhelpwhenneeded.

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One of the people I signed up justbefore the holidays, we talked justaftertheholidaysandshesaid,like,‘Thank you for gettingme throughtheholidays.Idon'tknowhowIwasgonna make it, you know, withoutthis.’

-Pharmacist

IncreasedAccesstoMentalHealthandAddictionsServicesandSupports

Theevaluationfoundthattheindividually-tailoredmedicationmanagementsupportdeliveredthroughthe Bloom Program contributed to an increase in the availability of mental health and addictionsservicesandsupportsatthecommunitylevel.Itachievedthisincreaseinaccessinseveralways:

1) It provided mental health and addictions care in rural communities that did not have otherresources(treatmentandnavigationalsupport),therebyaddressingresourcegapsinthecurrentmentalhealthandprimarycaresystems;

2) Itprovidedcaretopeoplewhowerewaitingtoaccessothermentalhealthandaddictionscare;3) It increased the range of mental health and

addictionscareoptionsservicesgenerally;and,4) Itprovidedfinanciallyaccessiblecare.

In addition, the evaluation found that, while not a keycomponent of the program’s initial design, one of theaspectsoftheprogramthatmanypatientsvaluedmostwasthe social support they received from the Bloom Programpharmacist related to living with mental health andaddictions problems or, occasionally, other issues (e.g.,financial). Each of these findings are discussed in greaterdetailinthissection.

1. Bridgingservicegaps

Intheinterviews,patients,physiciansandpharmacistswereaskedtotalkaboutthevalueoftheBloomProgram -whydidpatients access it andwhydidphysicians andotherhealth careproviders supportpatientinvolvementinit.Toagreatextent,therespondentssaidthattheyfoundvalueintheprogrambecause itaddressedagap inavailablementalhealthandaddictionsservices in the localcommunity.Theseserviceswereeithernon-existentorverylimitedinwhattheycouldoffer.Insomecases,patientssaid that the services thatwereavailableprior to theBloomProgramweredifficult toaccess so theychosenottousethem.

Patients IfeelverygratefulthatIhavesomeonerightnowbecauseIdon'thaveanybody.

WhenitcomestomentalhealthIhavenoproblembeingbrutallyhonest.In[townname]itisactuallyscaryhowfewresourcesthereare.They'reessentiallynon-existent.

TheBloomProgrammayhavemade a particular impact on increasing access to care and tomeetingpatientneedsinruralcommunitieswhereaBloomProgramwasoperating.Overhalf(13)oftheBloomProgrampharmaciesoperatedinruralcommunities.

Patients Itisasmallcommunityandthereisn'talot,especiallywithmentalhealth.

[Townname]issosmall,Iknowthere'snothing.

Physician Especially rural Nova Scotia, because like I say, people in [rural community] or [otherrural community], they travel somuch just to come to clinic and so if theyhave these

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facilitiesavailableintheirlocalpharmacies,[and]theyhavealittleproblem-they’rejustdoseinitiatingorescalatingorcross-tapering-theyjustgoandtalktothemandstayaspart of the program…. Iwould strongly recommend peoplework in collaborationwithpharmaciesandpharmacists.

Pharmacistsworking inruralcommunitiesconsistentlysaidthataccesstomentalhealthandaddictioncarewasoftenchallenging in ruralcommunitiesandthey felt that theBloomProgramhelpedmeetasignificant need.Many felt that theywere able, for example, to help patients save on travel timebyofferingcarewithinthepatient’sowncommunity.

Pharmacist Thebiggestadvantageisthatyou'repromotingthatwholesenseofcommunity,makingsure that people have access to resources. You know, they don't have to drive 40minutestofindhelporresources,andknowingthattherearesupportsavailable.

Pharmacist I thinkforeveryoneandtheir families it'sanotheraddedresourcethat'srightathomefor them.That'sapositive thing,especially in ruralareas likeours.Andeven thewaitlists in some communities are so long to get mental health services that it’s a placewheretheyknowtheycangotoontheirscheduleandgethelpwhentheyneedit.

2. Providinginterimcare

TheBloomProgramwasalsoabletosupportpatientswhowerewaitingtoaccessotherservicesorwhowere left without supports when health care providers such as psychiatrists or counsellors wereinaccessible. Somepatients recognized thatdemand formentalhealthandaddictions services is highandthattheBloomProgramprovidesaninterimlevelofsupportwhilewaitingfororintheabsenceofmoreformalmentalhealthandaddictionscounselling.Itwasclearthatpatientsvaluedtheeasyaccessandsocialsupportprovidedtothembytheirpharmacist.

Patients Well,mycounsellor leftforprivatepractice,andsoshedroppedallofherclientsatthehospital,andthey'resayingwedon'thaveanotherpersontofillallthesepeople.SoI'venevergottenasessionwithanotherperson, Iwasjustdropped.AndI'mona listtogetanotherone.Butthethingis[thepharmacist]wasperfect.…he'snotapsychologist…itjustmadeitlighter,youknowwhatImean?

I'mjustwaitingforthespecialisttoget intouchwithmeandconductan interviewandseewhereIstand.ButImean,Icanstillrelyon[pharmacistname]-theytoldmethat.Sothat'sagoodthing,thatifIneedthemIcangotothem.

Ihaveafamilyphysician,[physicianname]in[townname].Itusuallytakesonaverageofabouttwotothreeweekstogetintoseehim….

3. Reducedfinancialbarriers

TheBloomProgrammayhavealsoincreasedaccesstomentalhealthandaddictionsservicesbecausepatientsdidnotbearanyfinancialcostsforparticipating.Forsomepatientsonafixedorlowmonthlyincome,thiswaspartoftheappealoftheprogram.

Patients Travelisdifficultonthebus,one'smonthlydisabilitypension.Mybudgetgoesonlysofar!Soyes,thispharmacistwasgreatlyappreciated!

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Wellthethingis,there'snosupportforaprivatecounselunlessIpayandIdon'thaveanymoney.

4. Increasedrangeofmentalhealthandaddictionscareoptions

The evaluation found that the Bloom Program was able to support some people who would nototherwiseutilizeothermentalhealthandaddictionsservicesandsupportsforavarietyofreasons.TheBloom Program gave them another care option in their community. Accessing services through apharmacymayhaveofferedsomepatientswhatonepharmacistcalled‘aneutralspace’thatmayhavebeenmorecomfortableforindividualsaffectedbythestigmaoflivingwithamentalillnessoraddiction.

Pharmacists Somethinghappenedyearsandyearsagowhichnecessitated thehospitalizationofourpatientwhichledtoacompletedistrustofthesystem.

Foralotofthemitwasaneutraloutlet,aneutralpersonthattheycouldtalkto.Andnotonly talk toabout,youknow, theirmedicationsandconditionsbut therewasa leveloftrust thatwasbuilt, so, you know, theywouldprobablydiscuss things inamuchmorecomfortableway…

Physician Some patients, anyway, they are not that comfortable to go tomental health to startwithbutmaybethey'remorecomfortable talking to theirpharmacist.Even just today Ireferred one patient to the program because she had a bad experience with mentalhealthyearsago.Soshehasagoodcommunicationwithmeandwithherpharmacist,soIwaslike,‘Doyouwanttojointhem?’AndIthinkshe’lldothat.Sothat'sabonuswhenwehave-indeed,manyofmentalhealthpatientstheydon'twanttogobacktomentalhealth,right?

Aphysician said thathewould recommend theprogrambecausehe felt that itwouldbeparticularlybeneficial forpatientswhohavesevereorpersistentmental illness.Surroundingthemwithacircleofsupportive careoptions that includespharmacists in the communitywouldhelp themstaymotivatedandonasustainedpathtowellness.

Physicians [W]hethertheyseethedoctoronceamonthorwhethertheyseethepharmacistonceamonth,orgotoseeamentalhealthclinician,…ifthey’reseeingonepersoneveryweekdefinitelygoesalongwayinkeepingthem[patientswithseverementalillness]adherent,stable, motivated to make change. And so those sorts of patients, I think, very muchbenefit fromanextrahealthcareworker [pharmacist]being involved inamoredetailedway.

Onepharmacistwasalready supportingpeoplewhowere inamethadonemaintenanceprogramandshesaidthatshewaspleasedthat theBloomProgramgavehertheopportunity toprovideenhancedserviceoptionstothispopulationaswell.

Pharmacist Weworkquiteoftenwithaddictionsanditwasanothertoolwehadtoprovidethemwithbetterpharmaceuticalservices.Wewerereallyexcitedtobringthattothem,tosaythatwecanhelpwithmorethanjustthemethadoneprescriptionsandSuboxoneprescriptionsthatwereceived.

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5. Providingsocialsupport

Theevaluationidentifiedarecurringthemewithinpatientandpharmacistsurveysandinterviews:manypatientsaccessedtheBloomProgrambecausetheyneededandwanted‘someonetotalkto’.Theextentofthisfeedbackwasanunexpectedoutcomebecausetheprovisionofgeneralsocialsupportwasnotastated componentof theprogram’sdesignorpromotion. Theprogram’sdesign inherently recognizesthatpharmacistsroutinelyprovidesupporttopatientsandthedevelopmentofatrusting,therapeuticclinical relationship facilitates improvedmedicationmanagement.Many patients commented directlyonthissupportassomethingseparatefrommedicationmanagement,andthevaluetheyattributedtoitwasunanimouslyhigh.

Patients IdorememberthepharmacistthatfirstnightIwentinthere.Itwasalmostlikeshewasnotacounselorbut,youknow,somebodythatactuallygaveadamnandwaspassionateabouttheprogramandwasactuallytrulytryingtohelpme.

Themosthelpfulpartoftheprogramwasjustknowingthatyouhavesomebodythereonessentiallyaweeklybasis,orevenmorefrequentlyifneedbe,thatyoucantalktoaboutsomeoftheissuesyou'rehaving,mostlyrelatedtomedication.

Ifeltreallycomfortablewithherandshewasalways,everytimeIwentthere,shewouldalwaysaskmehowthingsweregoing,howIwasfeeling.

Ifitweren'tforthepharmacist,Iwouldhavenocounseling.

Pharmacists also consistently mentioned that they felt that Bloom patients appeared to value theprogram because it provided themwith someone that they could talk to andwhowould listen. Theprogram’s structure facilitated the provision of social support over several months and pharmacistsappliedtheircommunicationskillstopromoteapositivepatient-pharmacistrelationship.

Pharmacists From the feedback I get from her she really appreciates the ability to come in anddiscuss how things are going. The fact of having someone to discuss these things isimportant to her and seems to help because, you know, we're not therapists, butsometimesyouknow,somebodyjustwantstotalk.

[A]ndallbecauseyousatdownandtookthetimeto listen,andreally, that'swhat it'sabout.It'stakingthetimetolisten,andIdon'tmeanitfromacounsellingperspective-because certainlywe're not counselors - butwe have enough knowledge of differentthings that we can lead you one way or the other, you know, and help to get theresourcesthatyoumayneed.

50%ofthepeoplethatwehad,it'sjustalifelineforthem,like,kindoffeelingthattheyareat theirwit'sendandthen, like,okay,well there issomeonethatcaresor there issomeonetolisten.

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IncreasingAccessThroughNavigationalSupport

SupportingpatientsintheBloomProgramtonavigateNovaScotia’svarioushealthcaresystemsisoneoftheprogram’skeycommitmentsandexpectedoutcomes.Thefocuswasprimarilyonpatientsupportnavigating the mental health andaddictionssystem,althoughpatientscould also be supported navigatingthegeneralhealthsystem.

As noted, pharmacists wereprepared to deliver this componentof the program by completing arequired scan of mental health andaddictions services and supports aswell as by meeting with peopleproviding these services andsupports. During these meetings pharmacists would learn about the programs and services offered,meet staff, and take with them print resources to display in their pharmacy mental health andaddictions resourcecentre.Pharmacistswerealsoexpectedtoconductcommunityoutreachactivities(education sessions, etc.) that reached the mental health and addictions community.When workingwith individual patients, pharmacistswould utilize these local resources aswell as those listed in theNavigatorresourcepostedontheBloomProgrampublicwebsite.

As depicted by the infographic inAppendix M, pharmacists identified, communicatedwith, andmetwithanimpressivenumberofindividualsandorganizationsofferingmentalhealthandaddictionscareand support in their local communities. Bloom pharmacists identified 320 community-basedorganizations and services across the province,with each pharmacy identifying 12 local resources onaverage. They met with representatives from 153 community organizations, learning about thoseorganizations and sharing information about the Bloom Program, returning to their pharmacies withprint materials for display in the pharmacy’s mental health and addictions resource centre. Theaccumulatedtimeforthesemeetingswasover65hours.AfulllistoftheseorganizationsisprovidedinAppendixN.16

Navigationactivitiesbasedonchartandsurveydata

The chart analysis found that of the estimated 1687 actions taken by pharmacists in the care andsupportof201BloomProgrampatients,253actionswereinsupportofthepatient’snavigationofthehealthsystem(15%).

16Thedata likelyunderestimate the trueamountof timespent forging relationshipsasnotallpharmacies recorded timecommitmentsandongoingcollaborationbeyondtheapplicationpackagewasnotcollected.

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The pharmacy staff survey dataanalysis (n=25 representing 23pharmacies)foundthat13respondents(52%) reported that they helped aBloom patient, family member, orcaregiver to navigate or locateresources and seven respondents(28%) indicated that theyhadreferredBloom Program patients to mentalhealth or addictions services. It isworth noting that the respondents tothe pharmacy staff survey werepharmacists (and to a lesser extentpharmacy technicians and dispensaryassistants) that were not the leadBloom Program pharmacists but wereother pharmacists at the samepharmacy location. This indicates thatthe program was a team effortinvolvingmultiplepharmacydispensarystaff whowere involved in supportingpatient navigation and access tomental health and addictionsresources,services,andsupports.

This support was used by patients toaccess a range of services andsupports, as quantified in Figure 19.Based on the survey data, patientsreportedthatthenavigationalsupporttheyreceivedfromBloompharmacistshelped them access mental healthservices (61%); other services andsupports in the community (47%);access to health services for physicalhealth (42%) and access to supportsforaddictions(25%).

Importantly, the survey data foundthat the majority of patients weremoreawareofotherresourcesintheircommunity (72%) and were betterable to find services and supports inthe community as a result of being intheBloomProgram.Almosthalfofthe

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respondents (47%)saidthatthisnavigationalsupporthelpedthemfindanduseservicesandsupportsfortheirhealthfasterthanbeforeparticipatingintheBloomProgram.

The evaluation also reviewed open-ended written survey responses from patients regarding whatservicesandsupportstheBloomProgramhelpedthemaccess.Manymessagesreflectedthatpatientswere supported to access mental health and addictions services that include community-basedcounselors,psychiatrists, and specialist clinics toaddresseatingand sleepdisorders, aswell as familyphysicians. Other services and supports accessed through the Bloom Program included diabetesmanagementclinicsandrecreationalactivitiessuchasswimmingandcrafts.

Figure15:Typeofserviceandsupportaccessedthroughpharmacistnavigationalsupport

Improvingsystemefficienciesviapharmacist-facilitatedaccesstoothermentalhealth,addictions,andphysicianhealthcareservicesandsupports

Thisuseof theBloompharmacist’s timemayhavebeenused tohelp increaseefficiencieswithin thehealth care system (see also Communication and Collaboration). When patients living with mentalillnessand/oraddictionsappearedtolosecontactorbecomefrustratedwiththeirrelationshipwithoneormoremembersoftheirhealthteam,Bloompharmacistswerewellsituatedwithinthecommunitytohelpmaintain the patient's connection with the health system. There was evidence that community

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pharmacists supported continuity of care when relationships with other health providers waxed andwaned.

Patient IwasgoingthroughabitofsortofaroughpatchwithmydoctorandwewerehavingalmostnocommunicationatallandIthought,‘Oh,mygoodness!IstheresomebodywhowilllistentomeandanswermyquestionsaboutwhyamIonthismedication?’.

PatientandpharmacistinterviewsconsistentlyprovidedevidencethattheBloomProgramwaseffectiveat supportingparticipants tobetternavigate thementalhealthandaddictions system.Somepatientsneeded to access clinical counseling services and theBloompharmacistwas able to connect patientswithindividualandgroupcounselingservicesofferedinthearea.

Patient I think that itwas the secondor third session in, she [pharmacist]helpedmeoutand Ilearnedalotmoreaboutthelocalpsychologistandmyotheroptions.Andshedidsomeresearchonthat,like,betweenoursessions,theinformationandcontactinfo.forafewpeople… It'smade a pretty good difference. …[T]hemedication helped, but the biggerpart was going to the CBT course with the psychologist, but combined with it all, I'mreallygoodrightnowcomparedtothistimelastyear.

TherewasalsoevidencethatBloompharmacistswereabletohelppatientsnavigatethebroaderhealthsystemiftheclientwasinneedofotherhealthandsocialservices.Inthecasebelow,thepatientcouldnot afford diabetes supplies and the pharmacist referred her to an organization that could help heraccessfreeinsulinneedles.

Patient WhenabitofdifficultyaroseasfarasmyfinanceswereconcernedandIstartedusingthesame[insulininjection]needles,shesaid,‘Youcan'tdothat.That'swhat'sgivingyouthisstaphinfection.’WellIsaid,I'mverycleanandIshowerandthat,andshesaid,‘No,that has nothing to do with that, but up at [town name], if you go to the diabeteseducationcentre,youmaybeabletotalktothemandasa"hardshipcase"theymaybeable toassist youwith the cost of these items.’And sure enough, Iwentupand theywereabletohelpme.Ifoundthatjustagodsend.Sheknewwhatwasgoingonandsheknewwherebesttosendmetoseewhatwecouldgetgoing.AndImean,Ididn’trealizethat, you never know what's out there until, you know, you start doing someinvestigatingandshepointedmeinalltherightdirections.

ThenavigationneedsofBloomProgrampatientsappeartohavebeendiverse.OneBloompharmacisthelped a patient get a provincial health care card and another patient was supported to find moreappropriatehousing.AnotherBloompharmacisthelpedapatientaccessadietician in thecommunitybecause thepatientwanted to improvehereatinghabits.Anotherpatientwasput in touchwith thelocalhospital’sdiabetesclinic.TherewerealsoafewexamplesgivenofBloompharmacistsworkingwithpatientsaroundmedicationmanagementandnavigationsupportthateventuallyledtoemployment.

Pharmacist Probablythebestone[example]wasaladythatwassortofshutin,tookherawhiletoeventhinkaboutcomingtoseeme,andthenIworkedwithherforafewmonths.ShegotintouchwithsomeoneatPeer-on-PeerwithCMHA,endedupactuallygettingaparttimejob,endedupgettingafulltimejobinOntario,andmovedaway.

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Several patients said that they appreciatedhow theBloomProgrampharmacists advocated for themwithin the primary health care system. This included making appointments with physicians andadvocatingforthemontheirbehalf.Somepatientssaidtheyfoundthisdifficulttodoontheirown,inpartbecauseofthestigmasurroundingmentalhealthandaddictions.

Patients It just takesa lotofstressoffofme just tryingtodealwiththismyselfandwithmydoctorandtryingtomakeappointmentswithmydoctor…Shecommunicateswithmydoctorquiteeasilycomparedtomethroughemailsandthroughphonecallsand,youknow,justsavesalotoftimeandalotofstress.

I find that a lot of people dealingwithmental health issues, unfortunatelywe lackcredibility forwhatever reasonandhe [pharmacist] essentially, again,wasmyvoiceandwasabletocommunicatecertainthingstomydoctorthathemayotherwisehavenot understood himself…. What they did was they communicated to my doctorwithoutmehaving tomakedoctors’ appointmentsandwait. It's spedup thewholeprocess.

Extendingnavigationalsupporttonon-BloomProgrampatients

Anexpectedoutcomeoftheprogramwasthatpharmacistswouldbeabletobettercareforandsupportpeoplenotintheprogram(seeExpectationsintheMethodologysection).Somepharmacistsobservedthattheywereabletoprovidegreateraccesstomentalhealthandaddictionssupportstopeopleinthecommunity who were not formally enrolled in the program, people who heard about the programthroughparticipantsorwhosawprogramresourcespostedinthepharmacy.Inonecase,apharmacistworkedwithapersoninthecommunitywhomettheprogramcriteriabutwhoneverwantedtoenroll.The pharmacy applied the program principles and practices and the patient experienced positiveoutcomes.

Pharmacist He's probably one of the best candidates for Bloomandhe never enrolled, thought hedidn'tneedit.Wedidn’tuseanyoftheBloommaterialbutwedidcontacthisdoctor.Wemade a recommendation, medication was prescribed, we followed him up, did all thework we would have done with Bloom. Never could get him to enrol. And yeah, thepatientisfullyfunctional,backtohimselfandfeelinggreat,andeverytimeheseesmehesaysthankyouverymuchforthecareandtheexceptionalservicesthatyou'vegiventome. And to this point, he's never joined Bloom. So that's one of the quirky things, ourservicehasgot better even for patientswhoarenot inBloom.…It hasmadeusbetterpharmacists.

Navigationalsupportincreasesinter-professionalnetworking

As noted earlier, Bloom pharmacists were responsible for conducting outreach activities with localmentalhealthandaddictionsservice.SomeBloompharmacistssaidthatthisoutreachhelpedtocreateprofessionalnetworksthattheycontinuetouseintheirday-to-daypharmacypractice,independentoftheBloomProgram.

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Pharmacist I think that theadvantage is thenetworkingopportunityandtherelationships thatarebuilt in the community, which is sort of a prerequisite to being approved as a Bloompharmacy.So I think it isanadvantage.Thedisadvantage is, Iguess, it takes timeandeffort to create those relationships if they're not already there, but overall, I think it'sadvantageoustomakethatarequirement.

Despitetheadditionalworkittooktoconductnavigationaloutreach,thissamepharmacistfeltthatthenavigatorrolefitwellwithhervisionofthekindofworkcommunitypharmacistsshouldbedoing.

Pharmacist

Ilikethattheywouldseeusassomeonewhomightbeabletohelpthemfigureoutwhatthenextsteptodois.Evenjustmakingsuresomeonehasthemobilementalhealthcrisisnumber, that they know that that's a support that’s out there, or passing along thephonenumber for theoutreachprogramfor settingupanappointmentwith thesocialworkeratthementalhealthclinicthat'sclosesttothem,kindofthing,right?Ithinkwe'rejust trying tohelpgetpeopleconnectedasbestwecan.Thebiggestadvantage is thatyou'repromotingthatwholesenseofcommunityandasacommunitypharmacistwe'rekindofallaboutthataswell.

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Outcome2:MedicationManagement

Short-termoutcomes

- Medicationandotherrelatedhealthissuesareidentifiedandactedupon- Patientshaveincreasedknowledgeabouttheirmedicationsandhealth

Intermediateoutcomes

- Healthandmedicationissuesarebettermanagedand/orresolved

Evaluationquestions

- To what extent was the Bloom Program able to identify, act upon, and resolve patientmedicationandotherrelatedhealthissues?

- To what extent did participating in the Bloom Program result in patients increasing theirknowledgeabouttheirmedicationsand(general)health?

Keyfindings

- MostBloomparticipants(81%)utilizedtheBloomProgramtooptimizetheirmedicationregimentobettermeettheirhealthneeds,followedbymanagementofadverseeffects(24%)andsupportwithmedicationdiscontinuation(13%).

- Mostpatient-andpharmacist-identifiedmedicationissues(e.g.,unresolvedsymptomsor impairedfunctioning, adverse effects, etc.)were either resolved or improvedwhile the patientwas in theBloomProgram.Approximatelyoneinfouridentifiedmedicationissuesdidnotimprove.

- Overhalf ofBloomparticipants identified that theyhadotherhealth issues in addition tomentalhealth and/or addictions issues. The Bloom Program was able to work holistically with thesepatientstoidentifyandbegintoaddresstheseotherissues.

- Patients reported that their awareness and knowledge aboutmedications related to their healthincreasedwhiletheywereintheBloomProgram.

Analysis

ResolutionofMedicationIssues

TheBloomProgramwasdesignedprimarilytoaddressfivebroadcategoriesofmedicationmanagementissues(seeBoxB):

1)treatmentoptimization2)adverseeffect3)non-adherence4)medicationwithdrawal5)inappropriatepolytherapy

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BoxB:MedicationmanagementissuesaddressedintheBloomProgram

1. Treatment optimization: Following a standard trial of recent mental health/addictions pharmacotherapy,thereisnon-responseorpartialresponserequiringchangeinpharmacotherapy;

2. Treatment adverse effect: Experiencing a treatment-limiting adverse effect to current mental health oraddictionsmedication(s)requiringchangeinpharmacotherapy;

3. Non-adherence:Medicationrefusalornon-adherenceleadingtoacurrentoranear-recentdecompensationofmentalillnessoraddiction.

4. Medicationwithdrawal:Difficultytaperingandstoppingtreatmentforamentalhealthoraddictionsprobleminastablepatient.

5. Inappropriatepolytherapy:Takingmultiplemedications,includingpsychotropicsandnon-psychotropics,thatiscausingfunctionalimpairmentrequiringmodificationsincludingmedicationdiscontinuation(s)onthebasisofsafety,redundancy,andabsenceofindication.

Analysisofchartdata

ChartdataandinterviewswithpatientsindicatethattheleadingreasonforenteringtheBloomProgramwastoimprovesymptomburdenandleveloffunctioningthroughchangesinthepatient’smedicationregimen.Theneedfortreatmentoptimizationwasindicatedby81%ofpatientsenteringtheprogram,followed by 24% for adverse effects and 13% for support for discontinuing psychotropic medication(Figure16).

Figure16:Frequencyofmedicationissuesidentifiedbypatientsatenrolment

The initial assessment included a relatively comprehensive review of current or relevant pastmentalhealth, addictions, and physical health issues. This assessment also included a thorough review ofcurrent and relevant past medication use. Medication and health-related goals were discussed andprioritized.Thetypesofmedicationissuesthattheprogrampharmacistsfocusedonwereoftencomplex

80.6%

24.4%

13.4%

10.9%

6.0%

TreatmentopOmizaOon

Adverseeffects

MedicaOonwithdrawal

Non-adherence

Inappropriatepolytherapy

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andrequiredsignificantpatienteducation,collaborationandcommunications,research,andfollow-upassessment and care. Contributing to the complexity were the patient’s personal and financialcircumstances as well as the existence of comorbid health conditions. In completing their initialassessmentwithpatients,pharmaciststypicallyidentifiedupto3priorityhealthandmedicationissueswitheachpatient.Whiletheremayhavebeenmorethan3issuestobeaddressed,theintentionwastoidentifythoseofgreatestimportancetothepatient,relatedtothescopeofpracticeofapharmacist.Aselection of the health and medication issues, as documented in the initial assessments by thepharmacists,islistedinBoxC.

Throughoutthecourseoftheprogram,thepharmacistwouldworkcloselywiththepatienttoresolveorimprove the status of identified issues, including any additional ones thatmight arise over time, forexample asmedication changes weremade and the clinical relationship developed. The longitudinalapproach to carebuilt into theprogram’s structure supportedpharmacists andpatientsdeveloping astrong clinician-patient partnership. This relationship developed throughmultiple follow-up visits andcollaborationwithphysiciansandotherhealthproviders.

BoxC:Verbatimexamplesofclinicalproblemsdocumentedatassessment

Treatmentoptimization

Depression and anxiety are preventingpatientfromgoingtowork.

Insomnia. Mind doesn't shut off at night.Averagesleepis3hourspernight.

Anxiety and depression. Need bettermedication management and other nonmedicationtools.

Patientisexperiencingworsenedanxietydueto health, employment, social (family)problems. Not interested in attending asupport group. May benefit from onlineresource fromBloomwebsite to help lessenanxiety and open her up to the idea ofseekingprofessionalhelpforanxiety.

Quitsmoking.

Migrainesareimpactingdailyfunction.10-15dayspermonth.

Manage stress/anxiety. Husband and sonfighting cancer, mentally challenged son tocarefor.

Keephallucinationsfromreturning.

Agoraphobia/paranoia.

Depression/anxiety. Currently not wellcontrolled, but not interested in newmedication.

Depression exacerbated by marital issues,death of her mother, lack of work, andchronicpain.

Notworkingrightnowandwantstofeelwellenoughtoreturn.Cipralexisnothelpingwithsymptoms.

Anxiety is main concern. Increased afterstopped Effexor. Worse these last 2 weekswithstartingPaxil.

Optimizationofmedicationwithconsultationwithpsychiatrist&familydoctor.

Anxiety disorder and experiencing panicattacks for years. Several times a week, atnight or first thing in the morning. Bowelproblems,heartpalpitations.

Can feel her mood slowly elevating (moreenergy etc.) is there anything she can takewhenthishappenstopreventprogressiontomania?

Starting Abilify - titrating up slowly -replacement for lithium to help treat OCDanddepression->wouldlikesupportthroughthischange.

Effectiveness of Sertraline, doesn't seem tobehelping.

Insomnia-falling and staying asleep. Hasneverbeenwellmanagedfor20years.

Patient at risk of CV event due to poor dietandfamilialriskfactors.

Seeking therapy optimization for mentalhealthproblems (depression, hallucinations).

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Feelingextremelydepressed.

Alcoholism-wouldliketolowertheamountofalcoholintake.

Current regimen of Risperdal injection,loxapine & sertraline not controllingsymptoms.

Adverseeffects Hasa tremorall the time - is thereanythingthat can be done to improve this? Lithiumlevelsarefine.

Anorgasmiaduetoparoxetine.

Nightsweats/anxiety/moodswings.

Opioidaddiction.

Weightgainfrommedications.

Quetiapine isnothelpingwithanxietyand iscausing extreme intolerabledrowsiness/grogginess.

Experiences multiple side effects from hermedications(quetiapine,lithium,topiramate,etc.).…Weightgain:1997startedlithium170lbs,March2015,310pounds.

Has lithium induced nephropathy (maincomplaint: polyuria) - needs to titrate offlithiuminacontrolledmanner(anxietyaboutchange).

Daytime fatigue, weight gain and insatiableappetite.

Drymouth – so extreme that tongue is rawandbleeding.

Non-adherence Quetiapine caused numbing of thoughts.Reduceddose.

Patient has been too worried about sideeffectsofanti-depressantssorefusedtotakeanything.

Patient has issues with compliance.Benzodiazepine overuse/abuse +noncompliancewithmedicationstotreattheaboveconditions.

Not taking medications for anxiety ordepressionduetosideeffects.

Experiencing vision problems. Blood glucosenot well controlled. A1C 13. Non-adherentwithinsulinassheishavingtroubleaffordingfoodandthereforeusing insulinmay lead tohypoglycemia.

Medicationwithdrawal

Benzodiazepine withdrawal has beenintolerable – “hellish”. Incapacitated by day2.

Wishes to come off of methadone whileavoidingrelapseorwithdrawal.

Recurrent withdrawal symptoms fromclonazepam (clammy skin, diarrhea,nauseous,headaches).

Inappropriatepolypharmacy

Doesnot takehermedicationsproperly.Toomanyonboard-picksandchooseswhatshetakes.Doesnotknowwhattheyareallfor.

Other $980disability.$825rent.

Patientismalnourished.

Patient suffers from bulimia + requirescounseling.

Dietimprovement.BMIclassification(obese).

Nofamilydoctor.

Trouble with support groups due toinaccessibiltyoflocations.

SupportforAlzheimers–sister’sdiagnosis.

Onepharmacistsummarizedtheirroleinaninterview.

Pharmacist First off,we're looking atmedicationmanagement: Is this drugworking for you?Howlonghaveyoubeenonit?Isthisasideeffectfromthedrug?Aretheredruginteractions,drugdiseaseinteractions?

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Of the201patientchartscollectedofenrolledpatients,182 (91%)hadat leastone followupcontactwiththeirpharmacist.Theaveragepatiententeringtheprogramexperiencedfivetosixfollow-upvisitsover a six month period with their pharmacist and each visit lasted for approximately 20 minutes,however,therewasawiderangeintermsofthefrequencyofvisits,theirduration,andinthepatientslength of enrolment. More frequent and longer visits occurred earlier in the six month period, asnecessitatedbyclinicalneed,includingtreatmentassessments,ofthepatient.

At entry to the program, the number of current medications recorded in the patient’s Bloom chartaveraged five per patient and ranged from zero to 24. Patients enrolling in the program taking zeromedicationsatthetimeofentryhadrecentlystoppedtreatmentduetoalackofresponse,experiencedor worry of adverse effects, or for financial reasons. The most common medications wereantidepressants (72%), benzodiazepines and related hypnotics (53%), antipsychotics (28.9%), opioids(12%,7.5%ofwhomwereinanopioidmaintenanceprogram),andmoodstabilizers(10%).Therateofconcurrentmultiplepsychotropicuse, inclusiveofopioidsformaintenancetherapy,washigh(68%)aswas the rate of use of medications for physical health problems (71%). Concurrent substance use,thoughnotnecessarilyabuseormisuse,wasalsorelativelycommonamongprogramparticipants.Ratesof self-reported nicotine, alcohol, andmarijuana use were 39%, 37%, and 18%, respectively. Sixteenpercentofpatientsindicatedthattheyhadasubstanceusedisorder.

Healthandmedicationissuesatdischarge

Fromthechartreview,57patientsweredeterminedtobedischargedfromtheprogram,46ofwhomhadmetwith theirpharmacist and completed theprogram’sdischarge form.A full accountingof thedispositionofthepatientsenrolledintheprogramcanbefoundinProgramDatasection(Table13).Onthedischargeformpatientsratedtheirhealthandmedicationissuesasresolved,improved,unchanged,or worsened as a result of their participation in the program. There were 125 medication issuesevaluated. Seventy-eight percent of medication issues were considered improved (61%) or resolved(17%)and21%wereunchanged.SeeFigure17.

Figure17:Patient-reportedratesofhealthproblemoutcomesatdischarge(%)

1.6%

20.8%

60.8%

16.8%

Worse

Unchanged

Improved

Resolved

Worse Unchanged Improved Resolved

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Twoof125(1.6%)wereclassifiedasworse.Apatientwithphysicaldisabilityexperiencedweightgaininassociatedwithanincreaseindoseofolanzapinewhileparticipatingintheprogram,ratingtheoutcomeof“weightloss”asworse.Anotherpatientexperiencedaworseningofdepressivesymptomsinthefirstsixmonthsof theprogram.Thepharmacisthad recommended initiatingantidepressant treatmentonseveraloccasionsbuther familyphysicianpreferred towaituntil shecouldbe seenbymentalhealthservices.Monthslater,symptomswereexacerbatedwhenapersonalrelationshipendedabruptly.Shewas hospitalized briefly and shortly thereafter started on an antidepressant. Her time in the BloomProgramwasextendedbysixmonths.Upondischargefromtheprogramat12monthsheranxietyanddepressivesymptomsandpersonalrelationshipshadimprovedandstabilized.

The125healthproblemsassessedatdischargewereprimarilyrelatedtomentalhealthissuesandtoalesserextentaddictionsandphysicalhealthissues,includingpain,neurologic,andcardiovascularhealthproblems.Examplesdemonstratingthediversityoftheissues,actionstakenwhilethepatientwasintheBloomProgram,andtheoutcomeareprovidedinTable14.

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Table14:Verbatimexamplesofdischargehealthandmedicationissueoutcomes

Healthissue Action Outcome

Treatmentoptimization

Anxiety&depression Hasimprovedthroughtalkingaswellashavingherbettercontroloverasthma.Stillfeelsdefeatedanddrainedwithanxietymoreatnight.Butoverallsheisbetter.

Improved

Sleepdifficulty MelatoninandchangedEffexorschedule. Improved

Insomnia.Averagesleep3hourspernight,multiplemedications.

Sleeptherapy,weanedoffhypnotics.

Resolved

Improvedepression InitiationofCipralex,monitoringforeffectiveness Improved

Depression Spokeaboutwhatisgoingoninherlife,shefoundittherapeutictotalkaboutit. Improved

Didnotfeelcomfortabletakingvenlafaxine

Pharmacistcontacteddoctortoasktohavepatientswitchedtocitalopram.Doctorrespondedbutwouldn’tswitchuntilhesawthepatient.

Resolved

Depressiveepisodessurroundingmenses IncreasedPaxil,augmentedwithAbilify,controlledmensesviadepoprogesterone. Improved

Anxiety+OCDtendencies CBT Improved

Untreatedanxiety Mindfulnessprogram,changedworkandplace. Improved

Antidepressantineffective Sentlettertodoctor.Hedidnotact/respondonit. Unchanged

Paincontrol Changedtolong-actinghydromorphoneContin. Improved

Anxiety Meditation,speakingwithpharmacistduringBloom,speakingwithdoctor. Improved

Alcoholism Patienthasbeenindulginginmeetingswitholdsponsorforsupport Improved

Anxiety,anger,paranoia Nochangesinmedications.[Patient]feelslikethisprogramhashelpedalot.Shehasdecreasedanxietycomingintopharmacy,talkingtomeaboutherhealth/personalandmentalhealthissuesandfeelscomfortableifsheneedshelpinthefuture.Stillexperiencingangerandparanoia-HastalkedtoDoctoraboutreferraltopsychiatrist.

Improved

Chronicpain Acupuncture,triednortiptyline,massage,chiropractor,yoga Unchanged

Weight Controlledasthmabetter,thereforeallowinghertoexercisemoreandnotbeonprednisone.

Improved

PTSD Sertaline50mgstarted Unchanged

Seasonaldepression Lighttherapysuggestedtobecontinued Improved

Adverseeffects Medicationsideeffects Metregularlytodiscussmedicationsideeffects. Improved

Fatigue/insomnia Stillunabletoworkfulldays.Wefeelthetamoxifenmaybecausinghertofeelweakbutshestillhave2yearsleftonit.

Unchanged

Sertralinesideeffectmanagement Zantac150mgoncedailyhalfhourbeforesertraline. Resolved

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Decreasedsexdrive Switchedoralcontraceptive. Resolved

Non-adherence Nottesting[bloodglucose]regularlybecauseoffinances

Nowon5injectionsperdayofinsulin->seeingclinicforsupplies Improved

Nottakingmedsproperly Moreorganized-andknowswhattheyareforbutnow++financialissues Unchanged

Medicationwithdrawal

Lookingforamorenaturalapproach/wouldliketostopallmedications.

Wediscussedcurrentmedicationbutdidnotthinkitwasagoodideatostopeverythingabruptly.

Unchanged

Inappropriatepolypharmacy

Domperidone+Ezetrolnotneeded. Contacteddocfordiscontinuation.[Patient]feltfinewithoutthose. Resolved

Reductioninpillload. Changeinmeds. Improved

UnnecessaryOTCproducts Stopped Resolved

Other Finances,taxreturn. Hadanaccountantgothroughpapersandgetthingsstraightenedout. Resolved

Hadnotseendoctorforalongtime Helpedencouragevisittodoctor’soffice.Wasabletogettodoctorandtogetbloodworkdone.

Resolved

overlapinmedicationsfrom2doctors bothdoctorsaware->patientkeepingthembothinformedonwhatshe'son Improved

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Analysisofsurveydata

Patients who had completed the Bloom Program were invited to complete a survey voluntarily toprovidefeedbackabouttheirexperienceintheprogram.Thirty-sixpatientscompletedthesurvey.Theirresponses indicatedthatthemostfrequentservicesreceivedrelatedtoworkingwiththeirpharmacistto identify and resolve their health and medication issues (Table 15). They also indicated thatpharmacistsoftenprovidedsupporttopatientsinaccessingvarioushealthservices.

Table15:PatientsurveyreportofservicesandsupportsreceivedintheBloomProgram

Servicesandsupportsreceived Rate(%)

Reviewingmyhealthissue(s) 94Reviewingmymedication(s) 86Identifyingandprioritizinghealthissue(s)tobeaddressed 81Identifyingandprioritizingmedicationissue(s)tobeaddressed 72Makingplanstoaddressmyhealthandmedicationissues 75Changingmymedicationregimen 67Talkingwithmyfamilyorcaregiveraboutmyhealthandmedications 47Helpingmetoaccesshealthservices:

MentalhealthPhysicalhealthAddictions

583619

Assistingmeinfindingotherservicesandsupportsinmycommunity 42Providingmewithhealthinformationtoread(print/online) 58

Twenty-five patients responded to the patient survey question asking if theirmedication issueswereresolvedduringtheirparticipationintheBloomProgram.Fourteensaid“yes”,nineindicated“some,notall”,andtwoindicated“no”.Nineothersurveyrespondentsindictedtheywerestillintheprogramandtwoprovidednoresponsetothisquestionforatotalof36completedsurveys.

Survey participants were asked to describe what medication issues were resolved. Nineteen (53%)respondedandmost said thatparticipating in theBloomProgram resulted in them takingadifferentmedicationthatworkedbetterforthem.

Patients Ihadtohavemymedicationchanged.Thelastmedicationwasn’tdoingmeanygoodnomore.IamtakingVenlafaxine75mgtwiceadayanditisworkingwell.

Bloodpressuremed.Changedtohelpwithsideeffects.

Thesecondmostcommonlycitedinterventionmadebyapharmacistthatwasofbenefittothepatientwasarecommendationtochangethedosingregimen.

Patients IwastakingmuchmoreSeroquelthanIneededforsleep.

They[pharmacist]gotintouchwithmypsychiatristandheuppedthem[medications].

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SeveralpatientssaidthattheBloomProgramresultedinthembeingabletocomfortablywithdrawfromamedication.

Patients Stillintheprogram.AtpresentIamstilltaperingmedicationsIhavebeentakingfor20+years.

Weeningdownoffdiazepam.StoppedtakingmedicationthatIdidn’tneed.

Patientsurveyrespondentsalsocitedgeneralimprovedmedicationmanagementintermsoforganizingdoses,providingadherenceaidssuchasblisterpacks,andgeneralmedicationcounseling.

Patients IstartedgettingmymedsinblisterpackssoIcouldrememberwhentotakethem.

Timefordiscussingeachofmymedications,sideeffects,whatworksbest.Ifeltverygoodafter I finished the course because all my medication was discussed and I feel verycomfortablewithmymedications.

Seven patients (19%) responded to the question “What medication issues were not resolved?” Itappearsasthoughtheunresolved issueswere linkedtothenatureofthehealth issueexperiencedbytheparticipantratherthantheprogramitself,includinganinabilitytopayforneededmedicationsandequipment.

Patients PaI triedcomingoffLamictalbutstartedagain,but [I] thinknow itwaswithdrawaland Ishouldhavegaveittime.

Methadonedecreasedsignificantlybut[I’m]stillon.

The pharmacist did an excellent job trying to find alternate medications for all of mypresentmeds–noluck,lotofresearch.

Withrespecttophysiciansurveys,nosinglequestiondirectlyaskedwhetherthephysicianobservedanychanges related to medication management, however several physicians commented favorably onhavingthepharmacistdirectlyinvolvedinthepatient’smedicationmanagementissues.

Physicians They[pharmacists]cansolveproblemsupstreambeforetheybecomeexpensivedisasters.

Patientcentered.Reviewsthemedicationsasawhole.Educatesandsupportspatientsinmanagingmanypsychotropicmedications.

Pharmacistwasawareofpatientgoalsinmanagingmedications.Moreattentiveofanyconcerns or problems related to prescribing, bringing attention to the physician asneeded.

Theprogramallowedforon-the-spotmedicationschangesthatwouldn’tbepossibleinastandardfamilypractice.

Pharmacists’ survey responses (n=28) indicated they perceived overall improvements in quality ofpatientcare,patientrelationships,andpatienthealthoutcomes(Figure18).

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Figure18:Pharmacists’perceptionsofpatientcareoutcomes

Analysisofinterviewdata

The chart review and survey findings were reinforced by the patient, pharmacist, and physicianinterviews.MostpatientssaidthatparticipatingintheBloomProgramhelpedthemidentifyandaddressmedication management issues and that the Bloom pharmacist was integral to the process. Again,medicationoptimizationwas themost frequentlydiscussedmedication issue.A typicalpatient surveyrespondentindicatedthattheywerenotdoingwell,leadingthemtoreviewwiththeirpharmacisttheirhealthissuesandcurrentandpastmedicationstoexploreopportunitiesforchangeintheirmedicationregimen. Often a change in medication was initiated and sometimes doses were adjusted andmedicationswithdrawn.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Increasedcommunicaaonswithpaaents

Increasedthequalityof

interacaonswithpaaents

Benefitedpaaent'shealth

Valuableprogramforpaaents

Improvedpharmacist-paaent

relaaonship

Stronglydisagree Disagree Nietheragreenordisagree Agree Stronglyagree

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Treatmentoptimization

Patients My family doctor putme on a certainmedication [but] it wasn't working verywell. Icouldn'tsleep.IwasstilltryingitwhenIstartedtheBloomProgram.Iwastalkingwithmypharmacist.Sheexplainedtomeindetailthedifferenttypesofmedicationsandthebenefits and negatives of each one and she recommended that I try a differentmedication,whichI'mactuallyonnowanditworksalotbetter.

He[pharmacist]recommendedanewpillformetouse.Hewrotealettertomyfamilydoctorandherecommendedapilltoquietmedownandmakemethinkbetterandfeelbetter.AndnowI’mkindof inthemiddleof it. [Thepharmacist]helpedmeoutwith itandstillfromtimetotimewhenIgodownweeklytheytalktomeaboutit.IfIhaveanyproblemsthey'lldiscussitwithme.So,Iwasgladofthat.

Ithashelpedmethroughmyaddictionforsure.IhavemedicationthatI'mcomfortablewith which was more related to my needs instead of experimenting so much. It'snarrowedtoexactlywhatisactuallyworkingforme.

Data frompharmacists’ interviewsalsosupport theprogram’s focusonandbenefits topatienthealththrough enhancedmedication management. The comment below summarizes one of several similarsuccesses a pharmacist observed in caring for people with chronic insomnia for whom sleeping pillswerenottherightapproach.

Treatmentoptimization

Pharmacist Ihadanoldergentleman,he'sprobablylate70s,whohadafairlyseriousstrokeaboutsevenoreightyearsagoandhasdealtwithdepressionandinsomniaovertheyears.Hehadcometothepharmacyonedaylookingreallyhaggard,tiredandwipedout–reallysmartguy–andhewasaskingabout,youknow,sleepmedicationandthatsortofthing.He’dhadafewdifferentmedicationsthathe'dtriedbutwasjustnotdoingwell.SoweenrolledhimintheBloomProgramandhewentfromtwotothreehoursanight,withbrokensleepthathe'dbeengettingforalmostayear,togettingsevenoreighthoursofsolidsleep.Andthiswaswithinafewweeksofgettingridofanyofthesleepmedicationand that sort of thing, kind of gradually over the span of a few months. So that’sprobablybeenmybiggestsuccessandmostcommonformofsuccess.

Insomecases,thepharmacistworkedwithpatientsandthefamilyphysiciantoaddressaddictionandmedication safety issues, including reducing the risk of falls and overdose. Pharmacotherapy reviewincluded helping patients find better and sometimes safer alternatives, or withdrawal from somemedications,andpharmacistsprovidedsocialsupporttohelpmanagethechanges.

Medicationwithdrawal

Pharmacist Ihadanopportunitytohelpgetanelderly ladyoffofherbenzodiazepine.UnderusualcareIdon'tknowifwewould'veachievedthatbutwedidwiththisprogram.Iendedupseeing her once a week until we could get her stabilized. …I gave her positiveencouragement every single day for a while on the phone, ’You're okay, look, you'reokay’,andsherealizedthat,yes,shewasokaywithoutthemedication.

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Adverseeffects

Pharmacist One patient needed something for pain because she had tried to overdose on hermedicationsoherdoctorwantedhertohavesomethingsafer.

Sometimeschangingmedicationschedulinghadadirectimpactonthepatient’swellbeing.

Medicationoptimizationandadverseeffects

Pharmacist We worked with her family doctor not on changing the daily total dosages of themedicationbutadjustingthetimesandthequantityofthedosethroughouttheday,tothepointnowwhereher sideeffectshavediminishedandheranxietyhasdiminished.Sheseemstobealotbetterfunctioning…throughthedaywithalotlessanxiety,which,ofcoursewasamajorconcernofherspouse.Hehasmentalhealthissuesaswell.Theyweresortoffeedingoffofeachother.ThelastconversationIhadwithhimhethankedmeforimprovingheranxietylevels.

Determiningtheimpactofmedicationmanagementfromthephysician’sperspectivewasmoredifficult.Sevenof10physiciansinterviewedstatedthattheyrecalledwhichoftheirpatientswereintheBloomProgram and five stated that they found the program to be helpful in identifying and addressingmedication issues. They indicated that theBloomProgramofferedpatients a forum tohave in-depthdiscussions with an expert in pharmacotherapy and medication changes were made that generallysupportedbetterpatientfunctioningandcontributedtooverallimprovedmentalhealthoutcomes.

Treatmentoptimization

Physicians TheotherpatientIremember,therewassomereluctancestartinganewmedicationandthrough the BloomProgram, the discussionswith the pharmacist,we did start a newmedication. Thathelped facilitatea fairlybig change inmedication,and thepatient, Ithink,hasdoneverywell.

Iwouldsayifnotresolved,thenworkedon,youknow.Itdepends.Sometimesit'sjustalittle adjustment or sometimes it means changing the medication depending on thesituation.…Ihadonepatientwherewe'dtakenhimofflithiumandhewaskindofgoingbackon itand itwasprettycomplicated.So itwasgoodthatwehad– I justsee itasmorecollaboration,right?

Adverseeffects

Physicians I think, first and foremost, I see them as a resource to have discussions aroundmedications, andmore comprehensive discussions. I mean, I know I can talk about...dosages but I can't even tell you for the most part if things are tablets or if they'recapsules,right?AndIcansaygenerallywhenthebesttimetotakeitis,but,youknow,again, I thinkthatpharmacistsare farbetterplacedtoappreciateandunderstandthecommonsideeffects,notthatI'mnotbut…

One [patient]wasableweanoffoneandgoontoanotherand isdoingverywell. Theotheronewasableto, I think,regulatethedosingofseveralofhermedications.AndIthink that'smade their life, you know, their energy level, their level of sedation a lotbetter.

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Inappropriatepolytherapy

Physician Onepatient,therewerenumerousmedicationsandarealkindofattempttotitrateandweandowncertainmedicationswhilemakingsurethattheywereremainingstable,andIthinkthatwashelpful.

Medicationmanagement:successstories

PharmacistswereaskedtodescribeanexampleofsuccessrelatedtotheBloomProgram.Afewofthemarebrieflyreportedhere.

Pharmacists Awomanwasprescribedamedicationforanxietythatshedidnotwanttotake.Thepharmacist worked with her explaining what she could expect in terms of possiblebenefits and adverse effects. They reviewed several medication options in detail.Feeling reassured and informed, the patient agreed to a trial of the medicationprescribedbyherphysician.According to thepharmacist she experienceda completerecoveryfromherillness.

Aman had depression, chronic pain, and diabetes, among other health issues. Thechronicpainwasnotwellmanagedandwasnegatively impactinghisdepressionandotherhealthissues.Thepharmacistdiscussedwithhimhiscurrentmedicationregimenandreachedouttothepatient’sdoctor(viafax)withwhatshefeltofferedanevidence-basedandappropriatechangeinregimenforthispatient’schronicpain,diabetescare,andrelatedsleepissues.Painmanagement improvedrapidlyandwasassociatedwithimprovedsleepandsubsequentlymoodsymptoms.

Amanwasaddicted toalcohol, severely depressed,andtakingmultiplemedicationsthatweren’tworkingwellforhim.BloomProgrampharmacistshelpedhimreachouttohis family physician who then worked collaboratively to stabilize his symptoms andmedications.

A man with ADHD and other mental health issues was experiencing erectiledysfunction that was worsening over the past few years. The Bloom pharmacistdevelopedaplanwiththepatientthatincludedauseofasmalldoseofacompoundedmedicationthatmadethesexualsideeffectsmoremanageableforthepatient.

A male patient was started on a ‘pill pack’ to improve medication adherence. Thepharmacist thenworked toaddresshisoveruse of unrequiredmedications. Togetherwith the patient and physician they were able to reduce his use of multiplebenzodiazepines down to one and to completely wean him off of three othermedications.

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HolisticMedicationManagement

The BloomProgramwas designed to give priority to people livingwith severe and persistentmentalillness,however,itwasrecognizedattheoutsetthatmentalillnessisfrequentlycomorbidwithdrugusedisordersandbothareaffectedbyandimpactotherhealthcareissues.Assuch,theinitialassessmentisdesignedtobeholisticandidentifiesothercontributorstohealthandwellness.

Analysisofchartdata

Basedonpatientcharts,overhalf(56%)ofenrolledpatientsindicatedthattheyhadotherhealthissuesin addition to their mental health and addictions issues. Most of these health conditions werecategorized as pain and neurologic disorders and cardiovascular disease. The specific rates of thephysicalhealthconditionsdocumentedatenrolmentareprovidedinTable16.

Table16:PhysicalhealthconditionsreportedbyBloomProgramparticipants

Physicalhealthcondition Count Percentage(%)*

Pain&NeurologicDisorders 77 38.3

CardiovascularDisease&RiskFactors 56 27.9

GastrointestinalDisorders 29 14.4

EndocrineDisorders(Diabetes,Hypothyroidism) 27 13.4

RespiratoryDisease 21 10.4

Other (e.g. sleep apnea, skin conditions, liverdisease,bladderdisorder,kidneydisease)

47 23.4

*Percentagesbasedon113/201Bloomparticipantswhoreportedonphysicalhealthatenrolment.

Asnotedatthebeginningofthissectionandtabulatedinthepatientdemographicoverview(seeTables10and11,p.26-27),participantsintheBloomProgramreflectedtheNovaScotiageneralpopulationofpeoplelivingwithmentalillness.Useofothersubstances(e.g.,nicotine,alcohol,marijuana,andopiates)werefrequentaswaspolypharmacywithpsychotropics(68%)andtheconcurrentuseofmedicationsforphysicalhealthconditions (71%).A fewexamplesofphysicalhealth issuesandtherelatedmedicationproblemsarelistedinBoxC(p.52).

Analysisofinterviewdata

Interviewsconfirmedthat theBloomProgramwasable tohelpparticipantsaddressothermedicationmanagementissuesthatwerenotspecifictotreatingmentalillnessandaddictions.Bloompharmacistssupported patients to get basic medical tests done and encouraged and supported the adoption ofhealthybehaviors suchashealthydiet andexercise. Pharmacists alsoengagedpatients indiscussionsaroundstressreductionandencouragedtheuseofnon-pharmacologicaltechniquessuchasmeditationandcognitive-behaviourtherapyforsleepproblems.Thisholisticapproachwasviewedasbeinghelpfulbypatients,pharmacists,andphysicians.

Patients I started walkingmore and got out of the house because I tend to be a person thatwould say in the house all the time. So I did do those things and it didmakeme feelconsiderablybetter.

WhenIfirstwenttotheBloomProgram[pharmacistname]was-asdelicatelyaspossible

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asshecouldsaywas,youknow,youhavediabetes,youknow,perhapsifyoulostmaybe10 pounds or so that will help you. And I ended up losing 30 pounds on the BloomProgram. Andmy doctor did not say a singleword. Now inmymind if you lose thatmuch weight your diabetes should be re-evaluated, your blood pressure medicationshould be re-evaluated, you know, these are-those are the things that are gonnaimprovemy health other than themeds. So, you know, like I said there were lots ofthingsthatreallyhelpedimprovejustmyday-to-dayawareness.

Pharmacists One other lady, one of her problems was she was having a side effect from herquetiapine.…Weweredoingsomecheck-upsanditturnedoutshehaddiabetessoshe'sbeengettingextracarewithherdiabetesaswellasbeingenrolledinthisprogram.Wehavebeenabletokeeptrackandseehowshe'sdoingwithherdiabetesandhowthat'sworkingwithherothermedicationsaswell.

Oneofthepatientsweenrolled inOctoberhadnothadbloodwork ina longtimeandstoppedherthyroidmedicationsowehadherscheduleanappointmentwithherfamilyphysician, had her blood work done, got started back on thyroid medication andfollowed her up a lot closer.…[H]er low energy and not feelingwellmight have beenattributedtonottakinghermedication.

Physician Oneofmypatientswithopioidusedisordergotvaluable informationonsleepandtheencounterhelpeduncoverpsychosocialissuesIwasnotawareof.

ImprovingPharmacist’sPatientCare

SeveralpharmacistsindicatedthattheytookaholisticapproachtomedicationmanagementpriortotheBloomProgram,buttheprogram’sstructure,withitsmorein-depthassessmentandallocatedtimetoworkmorecloselywithpatients,allowedthemtoformalizethisworkandtoconductbetterfollow-upandmonitoringofinterventions.ThisaspectoftheBloomProgramiswhatsetitapartfromtheirregularpractice.Aphysiciancommentedsimilarly.

Pharmacists Wegotheextramileforthesepatients,youknow,soweknowifthey’restartinganSSRIand they’ve been on 10 already thatwe’re gonna call them in a couple days and say‘How’sitgoing?Doyouhaveanysideeffects?Whereareweat?You’resupposedtostillfeelawfulsojusthanginthere.’Sometimesit’sjustthatoutreach.

TheBloomProgrampatientsknowmore-Idon’tlikeusingthewordholistic,butyeah–there’smoretoit.It’snotjustdrug-relatedquestions,it’soptimizingdrugsandmakingsurethatthey’re[patient]intouchwithalltheotherresourcesoutthere.

IncreasedAwarenessofMedications

Analysisofinterviewandsurveydata

Oneoftheprogram’sexpectedshort-termoutcomeswasincreasedpatientawarenessandknowledgeoftheirmedications.Thiswasfacilitatedthroughtheseveralmeetingswiththepharmacistandpatientand differed from usual practice in that there was a shared expectation of follow-up meetings anddiscussions,aswellasdocumentationinthepatient’schart.

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Increased knowledge and awareness ofmedications took several different forms. Some patients saidthat meeting with the pharmacist to talk about their medication helped them learn what theirmedications were for, how they worked, what common side effects they could expect, and how tomanage them. Some patients indicated that they learned important information about medicationsafetyandsomesaidthattheylearnedmoreabouttheirparticularmentalillnessandaddiction(s).

Patients I have a much better understanding of what I'm taking, the effects, side effects,combinations,… it's justopenedawholewidenewdoor formetounderstandwhat isgoingonwithmymedications.

Ifinditwasareallygoodplacetolearnaboutwhatmyoptionswere.Like,fromherwediscussedthemedicationsandstuff,certainproblems,youknow, likeanxietyandstufflikethat. I learneda lotaboutthemedicationanddifferentaspectsof itwhile Iwas inthere.

Somephysicians also echoed the value of the program fromamedication awareness and knowledgeperspective.Onephysicianwroteinasurvey:

Physician Patient centered. Educates and supports patients in managing many psychotropicmedications.

PatientEmpowerment

Analysisofinterviewandsurveydata

AcoreprincipleoftheBloomProgramistoprovidepatient-centeredcare.Thepatientissituatedattheforefrontoftheirpersonalhealthcarejourneyandtheyarelistenedto,informed,respected,andhavecontrolovertheirownchoices.Collaborationamongthepatientandotherpeoplewithintheircircleofcareisvaluedandencouraged.

Providingpatientcenteredcare isconsideredacriticalpartof theBloomProgram’stheoryofchange:whenpatientsaremeaningfullyinvolvedandfeelincontrolofdecision-makingrelatedtotheirpersonalhealth theyaremore likely to take steps to improve it andpositivehealthoutcomesaremore likely.While not explicitly asked in the patient survey and interviews, multiple patients, physicians, andpharmacists said thatoneof theoutcomesof theBloomProgramwas that itempoweredpatients totake greater control over their health. This likely stems from the program’s strong patient-centeredphilosophy.

Physicians Mypatientswhoparticipatehavegreaterself-efficacy.

Ithinkthatthere'smuchmorediscussionaroundoptionsofmedicationandsoIthinkthepatientsfeel liketheyaremore,they'vehadabiggerdecision,arole inthedecisionofwhatmedicationisgoingtobeusedorwhatdoseisgoingtobeusedorwhenit'sgoingto be re-evaluated. And I think that really goes a long way to empowering patients.They’regoingtobemuchmoreadherentwiththeirmedication.

One of my very articulate patients, he had comorbid alcohol addictions as well as amood disorder and he explored far more sort of varieties of medication that wasavailableworldwide.He'ddone internet searcheswith (pharmacist) andhe'd comeupwith, ‘Youknow,canItrythis forcravingsbutcontinuewiththis?’andheactually left

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me likeahuge stackof literature thathewas reviewing. So I felt thatdefinitely therewas,youknow,adifferencewithafewofthemwhoreally,youknow,feltencouragedtolookintotheirtreatmentaspartoftheprocess.

Patient Yeah, so everything that the BloomProgram contributed tomyhealthwas absolutelypositiveanditwasencouraginganditreallyfelt,andIhateusingthiswordbecauseit'soverusedbut,empowering.…itwaskindofawakeupcallalmost,achancetositdownand,youknow,gooverall thesemedicationsandasidefromtakingthesemedicationswhatelsecanIdotohelpimprovemyhealth.

RelationshipBuilding

Analysisofinterviewandsurveydata

Itappearsasthoughpositiveoutcomesinmanycaseswereachievedthroughconscientious,respectfulrelationshipson thepartof thepharmacistwith thepatient,particularlywithpatientswhomayhavenototherwisesoughtprofessionalsupport.Changesinmedicationmanagementwerenotmadeuntilatrustingtherapeuticrelationshiphadfirstbeenestablished.

Pharmacists We've had a couple of people that we've been trying to help, trying to get in theprogram. ...We'vehad to take it very slowand [be] very carefulwith them,but that'sbeen,youknow,we'vetalkedtothemformonthsandmonthsaboutjoiningandfinallyithappened.

[I]twasactuallymyveryfirst[Bloom]patient.Shehadcomeandshewasveryhesitanttostartmedication.Shehadbeenprescribed itandshewouldn'tstart it,andsheheldonto theprescription.Wehadmet fora coupleofmeetingsandshe said, youknow, IthinkI'mfinallyready.AndIdidn’ttalkherintoitbutItoldherabout,youknow,whatshecanexpectintermsofbenefits,sideeffects,andpotentialotheroptions.Itwasalotofeducatingheronthedifferentmedications.

Youcanslowlyseethatprogressionasacoupleweeksgoby…‘Youknowwhat,I'mnotsoscaredtoincreaseittoafulltabletnowbecauseIknowyou'regonnabethereforme.AndIknowifIcan'thandleityou'regonnafixit,you'regonnahelpme.’Whereasbefore,shewasvery,like,hopelessbecauseshesaid,‘Youknow,I'vedoneitsomanytimesandnobodycares.’

TheBloomProgrammayalsoofferasafeplaceforpatientstoexploreotherpharmacologicaloptions.Severalpharmacistssaidthatpatientssometimesdon’tfeelcomfortabletalkingwiththeirphysiciansifthemedicationstheyareprescribedaren’tworkingwellforthem.Theydon’twantto‘leton’thattheyaren’tfeelingwell.Thisdynamicwasechoedbyapsychiatristwhostated:

Physician IthinkthemostvalueasIsayisthatit'soutsideoftheteam.It'ssomewherewhereit'sasafeplacetosay,Idon'tlikethismedicationIwanttostopit.

A common theme in the physician interviews was an appreciation for the medication expertisepharmacistswereabletocontributetothepatient’soverallhealthcaremanagement,particularlyinthearea of psychotropic mediations. Several physicians said that they valued having a ‘second opinion’,especiallywithregardtopsychotropicmedications,regardingwhichwouldbeeffective,welltolerated,orsafer.Thisrecognitionofpharmacistexpertiseisalsodiscussedin‘RoleofPharmacist’.

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Onepsychiatrist said thathis/herBloompatientwas “overly reliant”onmedications. Thepsychiatristwas hoping that the pharmacist would be able to encourage the patient to engage in some non-medicationspecificactivities,suchasengaginginmorepsychosocialactivities,butthepharmacistwasnotsuccessfulinsupportingthepatientinthisarea.Thepsychiatristsaidthattheprocessconfirmedhisown analysis of the patient, which he viewed as helpful even though it did not lead to any specificchangesinthepatient’scare.

IndividualswhodidnotcompletetheBloomProgram

Loss to follow-up and lack of concordancewithmanagement plans are commonplace in health care,especially inmental health and addictions care. This was recognized by Bloom Program pharmacistsearlyonandraisedwiththeprogramimplementationteam.Theynotedthatmanypeopledeclinedtolearn about or join the program and several who did enroll were quickly lost to follow-up or weredifficulttoengagewhileintheprogram.

Of the 201 patients who enrolled in the program, 10% did not return for a follow-up meeting. Theperspectivesofthisgroupofpatientsarenotreflectedinthisevaluation.Assuch,theirreasonsfornotcontinuingtoparticipate,whetherprogram-related,illness-related,orpersonal,cannotbeelucidatedatthistime.

Ofthegroupthathadoneormorefollow-upvisitswiththeirpharmacist,thefrequencyandpatternofvisits was highly variable. A not insubstantial proportion had very few follow-up contacts. Eighteenpercent lefttheprogramwithinthreemonthsofenrolment.Othersremainedintheprogramofficiallybutdidnotmeetregularlywiththeirpharmacist.

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Outcome3:CommunicationandCollaboration

Short-termoutcome

- Pharmacistsandphysiciansarecommunicatingaboutpatientcare.

Intermediateoutcome

- Careprovidersarecollaboratingtomeetpatient’sneeds.

Evaluationquestion

- Towhat extent did theBloomProgram change communication betweenpharmacists andphysicians andwere there examples of pharmacists collaboratingmorewith other healthcareprovidersasaresultofBloomProgram?

Keyfindings

- Mostphysiciansandpharmacists reported thatcommunicationsandcollaborationsaroundBloompatientmentalhealthwereenhancedorconsistentwithwhattheywerealreadyexperiencingpriortoBloom. This is grounded in the recognition thatpharmacists contribute valuablemental healthpharmacotherapeuticexpertise.

- Thereweremany examples cited by patients, pharmacist, and physicianswhere pharmacists andphysicians successfully communicated and collaborated for the purposes of advancing positivehealthoutcomesforBloomProgrampatients.

- Somephysicianssaidtherewerechallengesregardingcommunications,primarilythattheywerenotalwaysawareofwhowasenrolledordischargedfromtheprogramandwhattheirongoingstatuswasvis-à-visprogress.

- Somepharmacistsreportedthattheyattemptedtocommunicatewithphysiciansbuttheywerenotalwayssuccessfulinbeingabletogeneratearesponse.

- PatientsrecognizethevalueofincreasedcommunicationandcollaborationamongpharmacistsandphysiciansandappreciatedwhenitoccurredintheBloomProgram.

Analysis

Oneof thecommitmentsof theBloomProgram is toprovidepatientswithenhancedcommunicationandcollaborationwith theirotherhealthcareproviders,especially thoseworkingwithinprimarycareandmentalhealthandaddictionsservices.Theprogramexplicitlyrecognizesthatnosinglememberofthepatient’s circle of care can support thepatient in addressingwhat areoften complex and almostalwaysdeeplyinterconnectedmentalandphysicalhealthcareproblems,issues,andneeds.Pharmacistscontributeunique, specialized skills andexpertise, aswell asobservationsbasedon their interactionswiththepatient,butpatientcareisoptimizedwhenpharmacistscanintegratetheirworkwiththatofthepatient’scircleofcare inorderto fullysupportpositiveoutcomesregardingresolvedor improvedmedicationmanagementissues.

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There isn't a day goes bythatIdon'thavetospeaktoapharmacistsomewhere.

-Psychiatrist

Communications

AsnotedinSectionIII,ProgramDescription, itwasexpectedintheBloom Program that communication between pharmacists andphysicianswould be based on their usual format, which may bedifferent depending on the pharmacist-physician relationship.Pharmacists and physicians often communicate with one anotheronadailybasisvia telephoneor fax.Basedonthisknowledge, faxtemplates were provided for pharmacists in the Bloom Program materials. Templates included theBloom logo and were intended for use when informing physicians about a patient’s Bloom Programenrolment. Ongoing communication mechanisms were left to the discretion of the pharmacist andphysicians. Pharmacistswereencouragedtodocumentallcommunication,whatevertheformat,withotherhealthcareproviders.

SURVEYDATA

Physiciansurvey

Oftheeightsurveyresponsesfromphysicians,4physiciansindicatedtheycommunicated1to3timespermonthandtheother4indicatedlessthanoncepermonthforBloompatientcommunications.

Telephone,faxing,andinpersonvisitswerethemostfrequentlyusedvehiclesforcommunicationandalsothemostpreferred.Overall,thecommunicationapproachintheBloomProgramwasnotdifferentfromtypicalcommunicationpractices.

Physician Pharmacistwasawareofpatientgoalsinmanagingmedications.Moreattentiveofanyconcernsorproblemsrelatedtoprescribing,bringingtheattentiontothephysicianasneeded.

Fourphysiciansagreedthatthequalityofcommunicationwithpharmacistshasimprovedwhilefourchoseneitheragreenordisagree.Thefrequencyofcommunicationwasreportedtoincrease(i.e.,agree)byfourphysicians,whilethreeneitheragreednordisagreedandonedisagreed.

Patientsurvey

Eighteenof25(72%)BloomProgrampatientsurveyrespondentsindicatedthatpharmacistsweretalkingwithfamilyorcaregivers.Eleven(44%)indicatedthatthiswasusefuland11reportednotapplicable.Sixty-ninepercentofsurveyparticipantsindicatedthattheirpharmacistandphysicianworkedmorecloselytogetheronthepatient’shealthandmedicationissues.Only14%indicatedthattherewasnotanimprovementinhowthepharmacistworkedwiththeotherpeopleonthehealthcareteam.Fromthepatients’perspectives,therewasalsoenhancedcollaborationbetweenpharmacistandpatientwith89%indicatingthatthepharmacistworkedmorecloselywiththepatientsontheirhealthandmedicationissues.

Pharmacistsurvey

Forty-threepercentofBloompharmacistsurveyrespondentsindicatedthatthefrequencyofcommunicationwithphysicianincreased.Thirtytwopercentofrespondentsagreedthattheir

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relationshipswithphysicianshavestrengthened.SeventytwopercentofpharmacystaffsurveyrespondentsindicatedthattheBloomPrograminfluencedhowpharmacystaffcollaboratewithothersinthecareofBloomProgrampatients.

Pharmacystaffreportednumerousbenefitswithrespecttocollaborationinfreetextresponses:

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Interviewdata

Communication

ThereweremixedfindingsfromthephysicianinterviewsaroundwhethertheBloomProgramenhancedcommunicationbetweenpharmacistsandphysicians.

Of the 10 physicians interviewed, six said that they did not experience any problems regardingcommunication. They said that they received the Bloom faxes and that these were followed-up, ifneeded, to further discuss any suggested changes in medication management. One physiciansummarized the process he typically observed to communicate and collaborate with the BloompharmacistandtosupporttheworkthepatientwasdoingthroughtheBloomProgram.

Physician Itseemedtobemorethatthepatientwasabletoaccessthepharmacistwithissuesthattheywerehavingaround their symptomsor their sideeffectswith themedications,andthen the pharmacist was able to relay that tome, and sometimes I would just have aconversationwiththepharmacistagain,andthentheywouldrelaysomethingbacktothepatient, or it would cue me to contact the patient, you know, depending on thecircumstancesifIthoughtitwasrequired.

Apsychiatrist,whohad10patientsintheprogram,didnotexperienceanyproblemsrelatedtowhatshesawasimprovedcommunications.Overall,shefeltthattheenhancedcommunicationincreasedpatientsafety.

Physician Irememberoneofmypatientsjustdisappearedoffthefaceoftheearthand,youknow,hewasn'tcomingforourpatientappointments. IknowthathewasaccessingtheBloomthrough (nameofpharmacist).So I sortof said toher, ‘Ifatanypointhecomes to,youknow,getanyotherinformationaboutmedications’–becausehewasveryapprehensiveaboutLithium-thencouldyoutellhimthatwe'rereallykeentoconnectandwe'reworriedabouthim.’Andshedidandheconnectedandhe'scurrentlyaninpatientIhearin([nameofcommunity].

… It really sort of developed that kind of rapport for patient risk and safety, whereasotherwise, you know, everybody's just a name and you don't want to really give anyinformation,youdon'ttrustthatinformationtobekeptconfidential,whereashereitwasalmostlikeaworkingrelationshipthatwedeveloped.

There was a consistent theme in four of the 10 physician interviews that communication could beimprovedbetweenpharmacistsandphysicians.SeveralsaidthattheybelievedtheywerenotifiedwhenpatientswereenrolledinBloombuttheyweren’tcertainifpatientswerestillintheprogramoriftheyhadbeendischarged.Somealsosaidthattheyweren’texactlysureofhowmanypatientstheyhadinthe Bloom Program and two felt that communication procedures may not have been consistentlyapplied.

Physicians At thebeginning I remember receiving faxeswith, like,a letterheadanda smallnoteorsomethinglikethat,butthatdidn'tpersistandIhaven'treceivedanythinglatelysoIwasleftkindofwondering,‘Aretheseparticularpatientsstillintheprogram?Werethereotherpatients thatwere enrolled later on that they kind of never informedus about?’ So thecommunicationatthebeginning[there]wasalittlebit,butthenitjust-there'sbeenreallynocommunication.That'sunfortunateIthink.

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Thisisoneoftheissues.Idon'tknowwho'sinitandwho'snotinit,okay?IknowpeoplewhoareinitandsoIwouldhavehadIthinkcertainlyabouteightpeopleIwouldthinkinit,butIdon'tknowthatofficially.

OneofthesephysicianssaidthathewouldhavelikedregularupdatesorsummaryreportsfromBloompharmacistssothathecouldbothsupport theworkthepatientwasdoing intheBloomProgramandfeelconfidentthatthepatientwasn’tgettingmixedmessagesfromdifferentcareproviders.Theotherphysician(psychiatrist)saidthathefoundoutthattwoofhiseightpatientsintheBloomProgramwereenrolled after the fact. He would have liked to have had input into whether they were suitablecandidates. He felt that one client in particular did not benefit from participating in the programbecause it gave her an opportunity to engage in ‘splitting’, which he felt was pitting the Bloompharmacist against himself, her therapist. He suggested that the pharmacist maybe went beyondproviding non-specific support to the patient and this did not support the therapeutic work he wasdoingwithherasherpsychiatrist.

Athirdphysician(psychiatrist)saidthatshefeltthattherewasgoodcommunicationaroundmedicationmanagementissuesbuttherecouldhavebeenbettercommunicationaroundhowtobestengageandworkwithclientswhopresentwithmorechallengingbehaviors.Sheknewoneofherpatientsvaluedher relationshipwith thepharmacist and shewashoping that thepharmacistwouldprovide anothervoicetothepatientandhelpmotivatehertoconsidernon-medicationtreatmentoptions.Shediscussedtheclient’sparticipationinBloomwiththepharmacistandtheyagreedthatitmightbehelpfulforhertojoin.

Physician So I felt likeweunderstoodeachotherbut I didn’t getmuch feedbackaround,nordidtheyreallyconsultmearound,youknow,howtoengageher,howtoworkwithher,thatkindofthing.…Ithinkwhatalsowasn'tasuccesswasafterIreferredhertotheprogram,andthisisasmuchmyfaultIthinkasitisontheBloomProgramorthepharmacy'sfault,Ireallyhadnosenseofwhatshewasdoing.Ineverreallygotanyfeedbackuntilactuallythe stuff around the evaluation came out andwhen next Iwas talking to them I said,‘Hey,whateverhappenedwith..?’ ‘Oh yeah, shedidn't really follow through.’ Thatwaskindofit.

Theevaluationwasnotabletoidentifypreciselywherethecommunicationbreakdownsoccurred.TheremayhavebeensomechallengesengagingphysiciansintheBloomPrograminitiallythatresultedinanongoing problem with communication. Some pharmacists said that they would have liked to haveconductedbetteroutreachwithphysiciansorthattheytriedtoengagethembutwereunsuccessful ingeneratinganinitialresponse.

Basedontheinterviews,someofthechallengescouldalsostemfrombothpharmacistsandphysiciansneglecting toeither sendoutBloomcommunicationsor review incomingones.This couldbebecauseboth professions are challenged by extremely busy work environments and both pharmacists andphysicianssaidthatsometimesthings‘goamiss’or‘getmissed’.

Finally, there may have been some issues related to misconceptions and/or tensions related to theintent of theBloomProgramand/or pharmacist scope of practice. Several pharmacists reported thatthey repeatedly attempted to communicate with some physicians but they did not get a response.(Note:thisissuewillbefurtherexploredinaprocessevaluationconductedoftheprogramshoulditbeexpanded).

Pharmacists I'vewrittenseveralletterstothedoctorexplainingwhatI'vetakentobehis[thepatient’s]conditionandincludingrecordshehadinToronto.SoItriedtoputthatalldownonpaper,

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present it to thedoctor, suggesteda treatmentplan. I reallywanted toget the therapygoingearlyand Iwanted thedoctor to respond tome,allowme to initiate the therapybecauseIhadthewholethingwrittendownasaplan.Heneverrespondedtome.

Ididhaveafewmorepatientsinvolvedthatwenttodifferentdoctors.Ididn'treallyhearalotfromthemintermsoffeedbackatall, likeIwouldsendtheminformationandthenthepatientwouldkindoftalktothemaboutit.Theyneverreallycontactedme.

Thatwasoneof themore kindof disappointingaspects of theprogram forme so far Ithink,youknow,hopefullythatwillimproveandchange,youknow,'causeIdid,youknow,makephonecallsandsendfaxesandemailsandthatsortofthingabouttheprogramandneverreallyheardbackfromanyone…

In one case, a pharmacist described how she had contacted multiple health care providers in hercommunity to inform them of the Bloom Program and to generate referrals. She said that in herexperience, the physicians did not generally appear to be interested onworkingwith her to addressmentalhealthrelatedmedicationmanagementissues.

Pharmacist Andthenoneofhispatientswashavingissueswithcompliance.She[patient]seemedtobe going throughhermedications, despite blister packing them, earlier than she shouldhave.Soshe'saweekearlyoutofa28daysupplyandshegetsLexapramandshegetsacoupleofother,youknow,anSSRIandshegetsawholebunchofother things thatsheshouldn't be taking more of and there's always a story and I'd actually contacted thephysicianandsaid,‘DoyouthinkshewouldbeagoodcandidatefortheBloomProgramifshe's usingmore of hermedications or having problemswith things?’ And he basicallystated, ‘Do you know something I don't?’ ‘Like, well, no, I'm just- I'm trying to offersolutions,youknow?’Soyeah.And,youknow,niceman,justdidn’tgoasIwouldexpect,youknow,sowehaven'thadasinglereferralfrommentalhealthorfromanyphysiciansdespitecontactingthementalhealthorthehospital,despitecontactingnursesindividuallythatIknow,despitecontactingallofthepsychiatriststhatIcouldthinkof.

Collaboration

IncreasedcollaborationasaresultofBloomwasidentifiedasamediumtermoutcomeoftheprogram.Wheremedicationmanagement caseswere relatively straightforward, clear communication betweenthepharmacistandphysicianaroundmedicationchangesappearedtobesufficientto improveand/orresolvetheidentifiedissue(s).Whencasesinvolvedmorecomplexmentalandphysicalhealthproblems,collaborationwasrequired.

Overall, it was clear from both physicians and pharmacists that they recognized that collaboration isimportant to address and resolve complex medication management cases and the physician andpharmacistquotescitedaboveandthroughoutthisreportshouldreflectacommondesireonthepartofmanyineachprofessiontoengageinmorecollaborativepractice.Thereweremultipleexamplesgivenbypharmacists, physicians andpatients in the interviews thatdemonstrated that theBloomProgramwasableto increasecollaborationbetweenpharmacistsandfamilyphysiciansandpsychiatrists.Manyof these examples have already been cited in this report under the Medication Management andNavigationsections.

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We worked closely withone of the physicianshere and that's probablywherewegotmostofourpatients.

- Pharmacist

All of the physicians interviewed for the evaluation, regardless of whether they had concerns aboutcommunication procedures, said that they supported the BloomProgram and its focus on enhancingcollaborationtobetterservepatientslivingwithmentalhealthandaddictionsissues.Ingoodpart,thiswas because they said that they recognized, valued and often relied upon the expertise pharmacistsbring to patient care in the area of pharmacology. Several physicians said that this expertise isparticularlyimportantwhensupportingpatientswhohavecomplexmentalhealthdiagnoses.

Physicians ImeanI think it'sa fantastic idea, like, tohavemoreofacollaborativeeffort,because,youknow,moreisbetter,youknow,moreheads,accesstomoreexpertiseandIreallydoappreciate the feedback when I do get it …When you're dealing with narcotics they[pharmacists]areexperts inthefieldaswelland I think intermsofotherpatients, Idodependon them. It usually is onlywhen somethinggoeswrong, so itwouldbenice tokindof,youknow,havearelationshipbeforethathappenstokindofpreventit.

Just having somebody elsewho’s got experience, and also, if I’mgoing to startmixingmedication, a second set of eyes to watch for more subtle side effects. They[pharmacists] have a niche in terms of finessing the medications and being aware ofpotentialinteractionsorpotentialsynergisticbenefitsthatImaynotknowabout.

Several physicians also recognized that pharmacists are well positioned to provide input into howpatientsare functioningonmedicationsgiventhat they tendtohavemore frequent interactionswiththepatientworkingoutofacommunity-basedpharmacy.

Physicians Ioftencall them looking for collateral informationbecauseof their contactswith thepatient.

Ipersonallyfounditbeneficialtotalkaboutmedicationswiththepharmacistbecausethey feel they know the patient too,mentally, not just the prescriptions they use. Sothatwasverygood.

Pharmacists, despite some of them saying that they were frustratedwhen physicians did not respond to their communications, said theywantedtoworkmorecollaborativelywithphysiciansbecausetheyknewthiswasthemosteffectivewaytoproducepositivepatientoutcomesforthosewhohadcomplexmedication-basedmentalhealthneeds.Assuch,manytriedtoconduct theirworkwithpatients inawaythatreinforcedthework thepatientwasdoingwith their primaryhealth careproviderandpsychiatrist.

Pharmacists IwouldsaythatthesuccessoftheBloomPrograminourpharmacywas100%directlyrelatedtothephysicianinvolvement,there'snoquestionaboutit.

Wetrytokeepitquiteatightbondbetweenthemandtheirdoctoraboutmakingsurewemanage somedrug interactionsand things like that.…Wekindof try toenhancethat for their visits so that the doctor can target things, our issues, for them a lotquicker.

Thispersondidn'tknowiftheirdoctorwasdoingtherightthingbecausetheyfeltthedoctor would rush them through their interaction. So basically we researched thedoctor'ssuggestion,andintheircaseitseemedtobethebestsuggestion,soit'smorejust kind of like, you know, solidifying it in their minds and making them feel

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comfortablewiththedoctor'sdecisionandthereasonsbehindit.

OnepsychiatristsaidthatsheappreciatedhowBloompharmacistsworkedwithhertosupportpatientcare.

Psychiatrist I never hadanoccasionwhere, you know, they said, ‘Oh,we saw this patient at theBloomProgram,didn'tthinktheywereontherightmedssotheyshouldbeonthis’,or,‘they shouldn't be on this…’. And patientswho came, theywere encouraged to takewhat theywerealreadyprescribedandmaybeaddon something,but itwasneveradebateonanythingelse.

Itmadeourjobeasier;itdidn'treallycauseanyproblems.

The evaluation also found that patients appreciate that health care providers have different butcomplementary roles to play, understand the importance of health care provider collaboration, andwanttoseemoreofit.

Patients Mydoctorisoffsickrightnowandactuallywhenshecomesbackwearegoingtodoalittledecreaseinmedicationbutwehadtowaittillshecomeback'causeIdidn’twanttodoitwithoutherinthere.

There’s just somuchmore they can help people with when there aremore peopleinvolved in itandeverybodyprovidingcarebrings theirownslant to things. Soyourdoctorhasallthebestintentionsfromadoctor'sperspective,andyourpharmacisthasthebestofintentionsfromapharmacyperspectiveandsoon.Soifthey'realltryingtohelpfromthebestoftheirabilitiesthensomethinggood'sgonnacomeofthat.

…[A]fter I got all the options [from my pharmacist] I knew that I could go see apsychologist as an option because [my family doctor] said medication and therapycouldbenefitbetterthanoneortheother.Ididn'tthinkthathewasgoingtouse[mypharmacist’s] advice but he made a phone call and I ended up getting through tomentalhealthandintoaCBTprogram.

Onepatientsaidthathisphysicianwasnotinitiallyawareoftheprogrambutshowedinterestinitwhenthepatientdescribed it tohim.Thephysiciansupportedhis involvementandbegan toworkwith thepatient’sBloompharmacist.

Patient Theystarteddiscussingsolutions,possibilities,stufflikethat,youknowwhatImean?You know, like, the three of us basically worked as a team. … [H]e [physician] wasreallyimpressedwithit.

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Outcome4:RoleofthePharmacist

Intermediateoutcome

- Patientsaremoreawareofpharmacists’rolesinmentalhealthandaddictions.

Evaluationquestion

Towhatextentdid theBloomProgramchangepatientawarenessof thepharmacists’ roles inmentalhealthandaddictions?

Keyfindings

• Participation in theBloomProgramchangedhowpatientsviewed the roleofpharmacists in theirhealthcare.Patientssawpharmacistsastrustedhealthcareprofessionalsthattheycouldturntoformedicationguidanceandsocialsupport.

• The Bloom Program confirmed formany physicians that pharmacists have significantmedicationexpertisetocontributetopatienthealthcareandtheyareuniquelysituated incommunityhealthcaretoprovidepatientcarebecauseoftheirregularpatientcontact.

TheBloomProgramstructuresupportedpharmaciststoworktotheirfullscopeofpracticebyprovidingcomprehensive,longitudinalcareforpeoplelivingwithmentalhealthandaddictionsproblems.Oneofthepredictedmediumtermoutcomesoftheprogramwasthatpatientswouldpositivelyexperiencethedifferentrolesthatpharmacistscanfillasaresultofprovidingmorecomprehensive,longitudinalcare.Thischangeinroleperceptionwouldleadpatientstofeelmorecomfortableaccessingcommunitypharmaciststohelpthemidentify,understand,andmanagemedicationandrelatedmentalhealthandaddictionsproblemstheywereexperiencing.

Itisclearfromthedatathatthischangeinpharmacistroleperceptionbypatientsoccurred.Thepatientsurveyfoundthatoverthreequarters(78%)ofrespondents(n=36)feltthatparticipatingintheBloomProgramchangedtheiropinionabouttheroleofthepharmacistintheirhealthcareand94%agreedorstronglyagreedthattheyweremoreawareofthepharmacists'roles.

Whenaskedtoexplainwhattheysawasthepharmacist’sroleinmentalhealthandaddictionsfollowingtheir experiences in theBloomProgram, themajority of qualitative responses (survey and interviewscombined) could be broadly themed as patients seeing pharmacists more as a trusted health carepractitionerthatcanprovidemorecomprehensivementalhealthandaddictionsservicesandsupport.MostpatientsindicatedthatpriortotheBloomProgramtheirrelationshiptopharmacists,whileoftenpositiveandfriendly,wasprimarilybasedinthepharmacists’dispensaryroleformedicationsprescribedbytheirfamilyphysicianorpsychiatrist. Interactionswereregularbutbriefandfocusedmainlyonthepharmacistcommunicatinginformationrelatedtomedicationchanges.

TheBloomProgramallowedpatientsandpharmaciststodevelopadeeper,moretrustingrelationship,facilitated ingoodpartbecausetheprogramgavepharmaciststheopportunitytospendfocusedtimewith each patient, startingwith a comprehensive initial assessment, that allowed them to develop afuller understanding of theirmental health, addictions, and physical health problems, and to provide

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ongoing, patient-centred, holistic follow-up care. This resulted in patients feeling more comfortablespeakingwiththeirpharmacistaboutissuesthattheywouldnothavetalkedtothemaboutotherwise.Some patients said that they didn’t know that pharmacists could provide them with the range ofservices,care,andsupportstheyreceivedintheBloomProgram,withonepatientofferingtheexamplethat they didn’t know that pharmacists could ‘look into things’ for them (i.e., advocacy/navigationalsupport).Overall, patients consistently said that through their experience in theBloomProgram theycame to see the pharmacist as a health care professionalwhowas helpful, supportive and genuinelyinterestedintheirmentalhealthandoverallwellbeing.

Patients [Y]ouknow,yougointoseethepharmacist.Youjustpickupyourprescriptionandyougohome.YouknowwhatImean?Like,you'rejust,‘Hi,howareyou?’ButbeingintheBloomProgramandsittingdown…andopeninguptothemandlettingthemknowwhatIwasgoing through and stuff like that. I don't know... it just made me feel comfortableafterwardsbecausenowtheyknowmy issues, theyknowmyproblems, theyknowwhatI'mgoingthrough.

[Before]therewasn'tmuchinteractionright?LikeI'vesaid,youknow,justkindofgopickupyourmeds,say‘thankyou’,goonmywaykindofthing.Butnowit'slike,‘Howareyoufeeling?’, you know, ‘How are you?’ They seem that they're concerned and they'reinterestedinhowI'mdoingmorethanbefore.

I did not know that a pharmacistwould be so helpful, supportive, and involved in yourhealth.

Ifeelmorecomfortabletalkingtothemandknowtheyarealwaystheretohelp.

AsubthemeidentifiedinthedataanalysisisthatpatientsdidnotappeartobeawarepriortotheBloomProgramthatpharmacistshadahighlevelofpsychotropicmedicationexpertise,includingknowledgeaboutnewmedicationsonthemarket,differencesbetweenmedication,etc.Again,thisisashiftfromseeingpharmacistsinamoretechnicaldispenserroletothatofaknowledgeablehealthcareproviderwithmedicationexpertisethattheycanaccessfortreatingmentalhealthandaddictionproblems.

Patients Ididn’trealizejusthowmuchmoreup-to-datetheyareonthelatestmedicationsand,youknow,‘Wellifthisupsetsyourtummy,I'llwriteitdown,youtakethistoyourdoctor,seeifthismedicationwillhelp…’.Ireallyhavefoundthatmuchhaschanged.Ifeelthatit'smuchmoretrustworthy.Iknowthatthey'remoreuptodateonthemedicationsandtheymightbeabletoprovideyouareasonablerecommendation.Sothatmuchhascertainlychanged.Irespectthemenormously.

Idon'tknowwhatmyopinionwasbeforebutnowIseethattheydefinitelyaresomebodyIcanuseformysymptoms.

Inowseethatmypharmacisthasvastlymoreknowledgeonthesuitabilityofmedication.

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Physicians

ManyofthephysiciansinterviewedalsosaidthattheirinteractionswithpharmaciststhroughtheBloomProgramincreasedtheirunderstandingoftherolepharmacistscanplayinprovidingmentalhealthandaddictions services and supports. As noted earlier, most physicians acknowledged that pharmacistspossessahighlevelofmedicationexpertiseandsomesaidthatpriortotheBloomProgramtheywerealreadyturningtopharmacistswhentheyneededtodiscusspsychotropicmedicationoptions.

Physician Iusethemas,again,asoundingboardaroundtheprosandconsofmedswhenpatientsareconsidering,youknow,shouldIstartthismedicationornot,becauseIusuallyprovideafewoptions.I'llsay,‘Okay,prosandconstodrugA,prosandconstodrugB,butreallyyou'vegottolivewiththechoiceand,youknow,ifyouneedfurtherinformationtalktoyourpharmacist.’Sothat'smostlyhowIsuggestpatientsusethepharmacist.

Inthiscontext,theBloomProgramappearedtohelpsomephysiciansrenewtheirappreciationfortheexpertisepharmacistscancontributetoimprovingapatient’shealthandwellbeingandmanysaidtheywelcomed an enhanced role for pharmacists in supporting peoplewithmental health and addictionsproblems.Onephysician said she felt that theBloomProgramhelped to formalize the applicationofpharmacistmedicationexpertisetobettermentalhealthandaddictionspatientcare.

Physician IthinktheBloomProgramsortofformalizedthingsforpharmacists.Ithinkpharmacistsweredoing itadhocanyway.Theywere talking topatientsandencouraging them totake themedication but I think it gave a platform for pharmacists to officially enrollpeople into a program to discussmedication, discuss their concerns, interactions andtalkaboutcomplianceinaformalway,almostlikeanotherarmoftherapy.So,Ithink,you know, the good pharmacists were doing it anyway but this gave them morevalidationofwhattheyweredoingandhowimportantitwasinpatientrecovery.

Several physicians also said that they recognized that pharmacists are uniquely positioned in thecommunityhealthcaresettinginthattheyoftenhaveregularcontactwithpatientsinwaysthatotherhealth care providers may not. Over time, this ongoing interaction with patients results in thedevelopment of an important patient–provider relationship that should not be overlooked whensearchingforwaystobettersupportthisvulnerablepopulation.

Physicians Pharmacistsareabletoassistinprovidingdirectionandsupportoutsideofmedicationsto patients and may share similar goals of encouraging enhanced selfcare/psychosocial interventionsto improvewellnessanddecreasemedicationoveruseparticularlywhenotherstrategiesaremorehelpful.

From my perspective, especially patients who pick up medications every month, oreveryfewweeks,mysenseisthepharmacistsreallydogettoknowthemverywell,sotohavethatpersonbetterintegratedintotheteamprovidingcareeitherwiththeGPorwiththespecialist,orspecialistprograms,Ithinkwouldbereallygreat.ButIthinkforthat to happen there has to be something, you know, some of those conversationswouldbereallygreatbecauseIthinkit'sreallyeasytogetsortofstuckinbelievingthatpharmacistshave,youknow,anarrowerscopeofpracticeandthatmaybetheydon'thavetheskilltodoX,Y,andZeventhoughthat'swhattheprogramsaysthatthey're

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offering.Sothatrelationshippieceis,Ithink,especiallykey.

As noted in the above quote, there may be a need to provide more education to the physiciancommunityaboutpharmacists’fullscopeofpracticebeyondwhatis impliedbypharmacistsdeliveringthe Bloom Program.One physician said that hewas ‘impressed’ that pharmacistswere interested inbecomingmore involvedand takingonanenhanced role inprovidingpatientcare.Anotherphysiciansaidthathewasnotawarethatpharmacistscouldprovideservicesbeyondthosethatweremedicationspecific,providingasanexamplewhathe termedpsychosocial careandwhatpharmacists refer toassocialsupport.

Providingsocialsupportiswithinapharmacist’sscopeofpracticeandtheimportanceofitforpatientsintheBloomProgramwasanemergingthemeinthisevaluation.ManyBloomProgrampatientshighlyvalued the psychological support they received from their Bloom Program pharmacist. For many, itappears,thatthissupportwaswelcomedintheabsenceofformalclinicalcounsellingserviceswithinthementalhealthandaddictionssystem.Thiswasnotastrongthemeinthephysicianinterviewsbutitdidgetmentionedseveraltimesbyonephysicianinthecontextofsuggestingthatspecificpharmacistsmayhavebeenworkingbeyondtheirscopeofpracticeandprovidingtherapybeyondsocialsupport.

Becausethissupportwassohighlyvaluedbypatients–thedegreetowhichwasnotanticipatedinthedesign of the program – this issue could be directly addressed in future Bloom Program pharmacisttrainingactivities.ItcouldalsobeaddressedbyformallycommunicatingtothephysiciancommunitytheservicesandsupportspatientscanaccessintheBloomProgramandhowprovidingthesefallswithinthepharmacistscopeofpractice.

Pharmacists

Forpharmacists,itwasevidentfromtheinterviewsthatparticipatingintheBloomProgramgavethemgreateropportunitytooptimizetheirscopeofpractice,somethingthatmostappearedtofullyembracetotheextentthatitwasmanageablewithintheirworkenvironmentanddispensaryresponsibilities.Thisoutcome will be explored in a separate pharmacist-focused outcome evaluation if the program isexpanded, however their observations on how patients perceived their expanded role warrant briefmentionbecausetheysupportwhatpatientssaidintheinterviewsandsurvey.

Most pharmacists said in the interviews that the Bloom Program allowed them to get to know theirpatientsbetterandtheyfeltthatpatientsbegantoseethemmoreasclinicianswhowerepartoftheirhealthcareteam.

Pharmacists They see you as more of a clinician. Even though something like the Bloom Programinvolvesmuchmore clinicalwork thangiving a flu shot, it justmakes patients see youmoreinthatroleotherthan,youknow,thepersonthatgivesmemydrugsandchargesmethismuchatthecashregister.

Ithinkthattheysawusasbeingmorethanjustpillcounters,thatweactuallywereapartofthehealthcareteamand(they)askedusmorequestions,wantedouropinionandjusttrusteditmore.

I think it's supported our role with the patients a lot better that we could be, like, ahelpfulpartintheirhealthcareteam.SoIthinkit'sreallybroughtthepharmacistalittle

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bitmore intotheteamthanbefore.Sobeforetheyusedto thinkof it, itwas just themandtheirdoctorandnowthey'relikeoh,I'vegotthepharmacisttooandtheycanhelpuswiththisandtheycanhelpuswiththat,soit'sreallyhelpedraiseawareness.

Onepharmacisttalkedaboutthisinthecontextofchangingexpectationswithhispatient.

The expectation is there. It’s kind of shifted and changed in hismind that, you know,we'renotjustdispensingmedication.We'reactuallyprovidingthatbettercare.

Onepharmacistsaidthats/hehadnon-BloomProgrampatientscomeintothepharmacytogetnavigationalsupportbecausetheyhadheardfromBloomProgrampatientsthatthepharmacistwasprovidingthisservice.Thislikelydemonstratesachangeinperceptionoftheroleofthepharmacistwithinthelargermentalhealthandaddictionscommunity,arippleeffectoftheprogram.

Peopleknowthatit'sthereandthatthereissupport.…I’vegottenphonecallsfromalotofpeoplewhoarereallyjustlookingforit,tomakethoseconnectionsandhelpwiththenavigationsideofit.Alotofthemaren'tenrolledintheprogrambutwe'restillabletohelpwiththat.Soeventhoughthere'salotofpeoplewhohaven'tactuallygotenrolledIstillthinkthere'sanumberofpeopleoutsideoftheparticipantswhohavebenefittedfromtheknowledgeandconnectionswehavemadewiththeBloomProgram.

Foranotherpharmacist,fillingtherangeofpharmacistrolesthatshewasrequiredtodointheBloomProgramwasexactlywhatshebelievesistheroleofacommunitypharmacy.

Thebiggestadvantageisthatyou'repromotingthatwholesenseofcommunity,andasa community pharmacist,we're kindof all about that aswell. So, you know,makingsure that people have access to resources, you know, they don't have to drive 40minutes to find help or… Resources were pretty key and knowing that there aresupports available, you know, whatever they may be. Yeah that having a sense ofcommunityisreallyimportant,Ithink,formostpeople.

ThischangeinroleperceptionmayhavealsooccurredamongorganizationsandagenciesthatBloomProgrampharmacistseitherconductedoutreachtoorinthecourseofsupportingpatientnavigation.Inthesurveyofcommunityorganizations,halfofwhichwerecommunityorganizationsandhalfofwhichwereNovaScotiaHealthAuthority,75%(n=20)saidthattheiropinionabouttheroleofpharmacistshadchanged.Whenaskedhow,mostsaidthattheyhadagreaterunderstandingofthebroadrangeofknowledgeandskillsapharmacisthasandtheyseepharmacistsashavingmorerolesthanjustdispensingmedications.ThisshiftwasdemonstratedbysomeagenciesinvitingpharmaciststospeaktothemabouttheBloomProgram.

Pharmacist Icreatedarelationship,likeIsaid,especiallywithmentalhealthandaddictionservicesand,youknow,Istillhavethatnetworkinplace.Theywerehavingaquarterlymeetingand,youknow,theyactuallythoughtofmeandsaid,Ithink,thiswouldbeagoodopportunityforyoutocomeandexplaintheprogram.Anditwasnice'causetheysortoftookthestanceofadvocatingfortheprogramaswell.Soobviouslythatopenedupaprettywidelineofcommunicationbetween,youknow,thepharmacyandtheresourcesoutinthecommunity.

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ProgramFeedback

Patients,physiciansandpharmacistswereaskedinthesurveysandinterviewstoprovidefeedbackontheBloomProgram.Thissectionprovidesanoverviewoftheresponsesfromeachpopulationgroupandthe feedback is organized into three main sections: 1) value of the program, 2) what was liked theleast/program challenges; and, 3) areas for improvement. The survey data was compared with thatobtainedthroughtheinterviewsandcommonthemesordiscrepanciesarecommentedupon.

Patientfeedback

Keyfindings

- MostpatientsfoundtheBloomProgramtobe‘excellent;’or‘verygood’;almostall(97%)saidthattheywouldrecommendtheprogramtoothers

- Theprovisionbypharmacistsofsocialsupportwasahighlyvaluedprogramfeature,followedbymedicationmanagementsupport.

- Patients’mainadviceforprogramimprovementswastocontinuetodelivertheprogramandtomakeitavailableatmorepharmacies.

1. ValueoftheBloomProgram

IllustratedbyFigure19,almost90%of theBloompatientsurveyrespondents (n=36)ratedtheBloomProgram as ‘Excellent’ (69.4%) or ‘Very good’ (19.4%). Only 3% rated it as ‘Fair’ (n=36). Almost allrespondentssaidtheywouldrecommendtheprogramtoothers(92%33/36respondents).Nonestatedtheywouldnot.

Figure19:(A)PatientratingoftheoverallqualityoftheBloomProgram.(B)FrequencyofpatientswhowouldrecommendtheBloomProgramtoothers(%)

ThemainreasonswhyrespondentssaidthattheywouldrecommendtheBloomProgramtootherswerethattheprogramprovides:1)highqualitycare;2)well-informededucation/adviceaboutmedications;

Fair

Good

Verygood

Excellent

(A) (B)

Yes

Idon'tknow

Missing

No

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3)neededsocial support;and4)anotherneededmentalhealthandaddictions service/support in thecommunity.OtherresponsescanbefoundinAppendixO,Table1.

Someofthecommentsthatpatientswroteinthesurveyinclude:

Patients IthasopenedthedoortogettingthehelpIneeded.

Ithinkitsgreatbecauseherein[nameofregion]there’snohelpforgamblers

Ifindittobeaveryhelpfulprogramandwouldprovebeneficialtoanyonewhohasissuesbutnosupportinmentalhealth

SomanypeopleIknowcoulddefinitelybenefit

Ifitwereactuallyofferedonamorelongtermbasis,thereisnodoubtonhowbeneficialitwouldbe.WeNEEDmoreprogramslikethisanditcannotbestressedenough.

Thestigmaofmentalhealthpreventspeoplefromreachingout.TheBloomProgramisasafeplacetoreachouttomypharmacist.

The overwhelming majority of patients (88.8%) (n=32) said that participating in the Bloom Programmade a positive difference in their lives. Formost, this was because theywere able to access socialsupport from the pharmacist. The second most highly documented response was that the programincreasedtheirlearningandcomfortlevelwithmedications.OtherresponsescanbefoundinAppendixO,Table2.Someofthecommentsthatpatientswroteareasfollows:

Patients There’ssomeonetosharehowyou’redoinginyourstrugglewithyouraddiction.

Through the Bloom Program I have made new connections with health services.Betweenthetwo,Ihavemadegreatimprovementsinmylevelofanxiety/socialanxiety.

Itrustmydoctorandpharmacist

As above, the provision of one-on-one support was, by far, the aspect of the Bloom Program thatparticipants mentioned the most, followed up by being treated with respect and developing acomfortable, trusting relationship with the Bloom pharmacist. Other responses can be found inAppendixO,Table3.Someofthecommentsthatpatientswroteinclude:

Patients Access. Privacy. The pharmacist was absolutely professional and one of the mostintelligentpersonsoutthere,andpolitewithitall!

I liked that itwas very confidential and that thepharmacist actually treated youasapersoninsteadofjustapatientorcustomer.

An actual reliable resource in a community that desperately needs more accessiblementalhealthcarethatisofferedandthevaluableinformationgained.

Howunderstandingandcompassionatetheyallare.

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2. LikedleastabouttheBloomProgram

Mostpatientssaidthattherewasnothingthattheydidn’tlikeabouttheprogramorthatthisquestionwas ‘notapplicable’.A fewsaid that theywished theprogramwasmorewidelyavailableand longer.OtherresponsescanbefoundinAppendixO,Table4.SomeofthecommentsthatpatientswroteforwhattheylikedleastabouttheBloomareasfollows:

Patients Even if there could be a 3month revisit to follow-up after completion of the initial 6months program itself;mainly for those of us in rural communities, it would be bothaccessibleandbeneficial to somany?Ongoing care,1or2 visitsa yearmaybe? It'sagreatprogram.

Nocontinuity.Back(now)towhereIstartedbeforetakingpartoftheBloomProgram.(Also) [t]hatmore pharmacies did not get involved in such a beneficial program thatwouldhavehelpedtheirclients.

Familydoctordidnotwanttobeinvolved.Thattheprogramtooksolongtobeintroduced.

3. Areasforimprovement

Mostpatientsurveyrespondentsindicatedthattheydidnothaveanyadvicetogivetoprogrammanagersabouttheprogram.EverythingabouttheBloomProgramwas‘good’or‘great’.Forthefewrespondentsthatgaveadvice,itwasmainlytoadvertisetheprogrammorebroadlyandtoeitherexpandtheprogramtoothercommunities/pharmaciesortoextendthetimethatrespondentscanstayintheprogram.Someencouragedgreatercollaborationbetweenpharmacistsandphysicians.

Someof the comments that patientswrote for the advice theywould give toprogrammanagers arelistedbelow:

Patients Follow up appointment with pharmacy for ongoing meds. For those taking multiplemeds from multiple doctors/agencies, the pharmacy should be the point which theprogramsrevolvearound,soonedirectivefromthem,insteadofsourceordoctor.

Keepgoingwiththeprogram!AsIbelieveitcanbeveryhelpfulformanypeoplewhodonotknowwheretogo.Also,IfeeltheBloomProgramcouldbeadvertisedalittlemore,Ithinkalotofpeoplemaynotknowtheprogramisanoption.Onafinalnote,IwouldliketoseemorecooperationfromfamilyDr'setc.IfeelasiftheDoctorsdonotknowmuchabouttheprogramordonotwanttogiveitmuchthoughtorworkwiththepharmacist.Mypharmacisthasattemptedtocontactmyfamilydoctor.Hedidnotseemtowanttocommunicatewithmypharmacist,usuallygivingaonewordreply.

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Physicianfeedback

Asnotedinthemethodssection,despitemultipleattemptstoengagephysiciansinprovidingprogramfeedbackonly11physicianscompletedthesurveyandmanyquestionswerenotanswered.Asaresult,thequantitativesurveyresultsshouldbeconsideredweakevidenceandonlythequalitativeresponsesfromthesurveyarereportedbelow.

Overall, thesurveyresponsesvalidatedwhatwas learned fromthephysician interviews.Theprogramheldvalueforimprovedpatientoutcomesandfurtherworkshouldbedonetofacilitateconsistentandclearcommunicationbetweenpharmacistsandphysicians.

Keyfindings

- Most physicians who provided survey comments stated that they found value in the BloomProgramfortheirpatientsand/orthatitshouldbeexpandedtootherpharmacies.

- Bettercommunicationbetweenpharmacistsandphysicianswasidentifiedasthemainareathatcouldbeimproved.

1. ValueoftheBloomProgram

Most physicians responded that “yes” they would recommend the Bloom Program to their patients,howeverthiswasnotunanimous.Onephysicianindicatedthats/hewouldnotrecommendtheprogrambecause s/he saw nomeasurable benefit in their patient(s) who participated. It was not stated howmanyofthisphysician’spatientswereintheprogram.SeveralphysiciansprovidedcommentsonwhattheylikedmostabouttheBloomProgram:

Physicians Thatsomeoneinthecommunitywhomypatienttrustsmakesaconnectionwiththeminameaningfulwaytoenhancetheoverallcare.

Roleofenhancedcollaborationbetweenpharmacistsandother careproviders;havingpharmacistswhocanhelpprovideconsistentmessaging.

Patientcentered.Reviewsthemedicationsasawhole.Educatesandsupportspatientsinmanagingmanypsychotropicmedications

Teamworkandfurthersupportintreatingmentalhealthpatients.

When asked to describe how the program has benefitted them as health care providers, threephysiciansprovidedcomment:

Physicians Mypatientswhoparticipatehavegreaterself-efficacy

Reducedstressandimprovedmonitoringofpatients

Betterpatient’scare

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SeveralphysiciansmadecommentsabouthowtheBloomProgramingeneralcanmakeadifferencefortheirpatients:

Physicians Theycansolveproblemsupstreambeforetheybecomeexpensivedisasters.

Bettercommunication

Bringsmanagementofanaddiction to the communityandgivepatients theability tocontactforhelpwhenneeded

Itcannotinourareaasaccesstoprimarycarealreadyverygood,inotherareasitmayfillthatvoid

Two physicians also commented on whether the program affected how pharmacists and physicianscollaborate?

Physicians Bettercommunications,understandingtherationalesofchoosingcertainmedications

Communication. This program also serves to show providers that communitypharmacistsarefrontlinehealthcareworkers,nottechnicians

Of thephysicianswhohadexperienceswith theprogram,most said that theywould recommend theprogramtootherpatients.Onephysiciansaidthatmorecareisbetterforpatientswithseverementalillness:

2. Programchallenges

PhysicianswereaskedtoprovidefeedbackonwhattheylikedleastabouttheBloomProgramandsomeof the challenges they encountered. With respect towhat they liked least, two physicians said thattherewas nothing they didn’t like about theprogram, one said theywishedmorepharmacieswouldparticipate,andoneofferedthattheyonlyhadonepatientunwillingtobeengagedbytheprogrambutthiswasnotduetolackofeffortbythepharmacist.

Physician Onlyhad1patientwhowasfairlyunwillingtoengageinprogram.Thiswasdespitebesteffortsofpharmacistandrestoftreatmentteam.

One respondent said they felt the ‘execution’ of theprogramwaspoor andanotheroffered that thecostdoesn’tjustifytheexpense.

Physician [T]hefactitcostsmoneyanddoesn'tchangepatientcare.

Physiciansprovidedcommentonsomeofthechallengestheyexperiencedwiththeprogram.Commentsare provided below. Two of the responses reinforce physician interview data suggesting thatpharmacist/physiciancommunicationscanbeimproved.

Physicians Itwasnotavailableatallthepharmaciesthatmypatientsgoto.Asoftengettingpatientstoonlyfillprescriptionsatonepharmacyisachallenge,IdidnotencouragemypatientstochangepharmaciestoaccesstheprogramasIdidnotwanttodisruptthiscontinuityofcareifitexistedwithapre-existingpharmacy.

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Awarenessinmypatientpopulationislow.

Notsurewhichpatientsareinprogram,whatisbeingdonewiththem

Poorcommunication

3. Areasforimprovement

Fivephysiciansprovidedcommentaroundadvicetheywouldgivetoprogrammanagers.Mostresponseswereintheareaofincreasingawarenesstophysiciansandpatientsabouttheprogram.Informationonwhatpatientsarebestsuitedfortheprogramwasalsonotedasbeinghelpful.Onephysiciansaidbuy-infromphysiciansneedstobeaddressedandonephysiciansaidtheprogramshouldbecanceled.

Physicians Itmaynotbepracticaltohavetheprograminallpharmacies,howeverasaprescriber,knowingclearlytheclinicsthathavethisinitiativeaheadoftime,particularlywithnewpatientswhodonotalreadyhaveaspecifiedpharmacy,wouldbehelpful.Also,[it]wouldbehelpfultogetasenseofwhoarethepatientsthatarebestsuitedtotheprogram,soagaintheycanbeencouragedtoaccessit.

Usevideovignettesandsocialmediainthemarketingofit.Morepeopleneedtobemadeawareofthis.

4. Suggestionsfrominterviewedphysicians

All of the 10 physicians who were interviewed said that they supported the Bloom Program. Thesephysicians also provided valuable feedback on areas that could be improved, which is summarizedbelow.

Promotion

• Promote theprogramwithphysicians.Severalphysiciansmadesuggestionsonhowthiscouldbe done, including have Bloom Program pharmacists come in and speak tophysicians/psychiatrists directly about the program. Physicians appreciate the face-to-facecontact and education about programs and this will help physicians think about includingpharmacistsinapatient’scircleofcare.

• Make information (pamphlets, etc.) available in physicians’ offices to informphysicians abouttheprogramandthatphysicianscanhandouttopatients.

• Makeitcleartophysicianswhatpharmaciesinthecommunityareofferingtheprogram.

Communications

• Ensure there is a clear referral and pharmacist/physician communication system or protocoldeveloped that is consistently applied. Some physicians weren’t aware, for example, thatpatientscanself-refer.

• Developacommunicationsystemthatincludestheprovisionofregularupdatestophysiciansofpatientprogress.Onephysiciansuggestedaweeklyfaxwithasummaryofpatientprogressandnotificationofanyadviceorcounselthatpharmacistsgavetopatientssothatthephysicianand

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pharmacistweregivingpatientssimilarcounsel.

• Collaborate with physicians/psychiatrist early on in the goal setting process and, as above,ensurethereisregularfollow-upbetweenthephysicianandpharmacistonanyprogressorlackthereof.Onephysiciansaidhewouldwelcomeapharmacistreachingouttohim/heriftheyarestrugglingwithhowtoengageapatientearlyonintheprogram.

Useoftheprogram/referrals

Severalsuggestionsweremadeforhowprogramreferralscouldbeincreasedandbetterfacilitated:

• Whennewprescriptioncomeinforanewpsychiatricmedicationorchangeindose,pharmacistscouldviewthisasasignalthattherehasbeenasignificantchangeinthepatient’sdiagnosisorcondition. This could flag for the pharmacist to contact the physician and ask/suggest if thispersonisacandidatefortheBloomProgram.

• Define for the physician who would be good candidates for the program so they can makeappropriate referrals. Some physicians weren’t clear if good candidates, for example, werepeoplewhoarealreadymotivatedtomakemedicationmanagementchangesorthosewhoarein the pre-contemplative or contemplative stage. Can the pharmacist do motivationalinterviewingwiththepatienttohelpinthisregard,andifnot,thenperhapsitneedstobeonlypatientswhoaremotivatedtomakechanges.

• Makeitmandatorythatprescribersareinformedwhenapatientisenrolledintheprogram.

Pharmacisttraining

• Developawaytoensurethatallpharmacistsupportstaffhavedemonstrableknowledgeaboutandsensitivitytomentalhealthandaddictionsissues.

Accessequity

• Peoplewhohavelimitedincomeslikelygettheirprescriptionsfilledatthecommunitypharmacythathasthelowestdispensingfees.TheBloomProgramshouldbeofferedatthesepharmaciestoensuregreaterequityofaccesstotheprogram.

General

• Continuewiththeprogrambecauseof itsdemonstratedsuccess,butcontinuetomonitorandevaluateitmorebeforeitisfullydeliveredonaprovincialscale.

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PharmacistFeedback

Keyfindings

- Pharmacistshighlyvaluedprovidingmorecomprehensivecaretopatientsbecausetheysawtheneed and they valued providing better quality care, which they also found professionallyrewarding.

- Issuessuchasprogrampaperworkrequirements,schedulingpatientappointmentswhenthereis pharmacist overlap, and/or supporting complex/high patient needs for social supportwerethreeprogramareasthatwerechallengingformanypharmacists.

- Pharmacistswanttoseetheprogramcontinueandfeel itneedstobebetterpromotedwithinthepublicandamongthephysicianandhealthcareprovidercommunity.

1. ValueoftheBloomProgram

Based on themed qualitative responses in the pharmacy staff surveys (n=25), three aspects of theprogramwerelikedbypharmaciststhemost:1)providingindividualizedone-on-onesocialsupportandbetterinteractionswithpatients;2)supportingimprovedpatientoutcomes;and3)theprogramallowedthem to deliver better care to people living with mental health and addictions problems. OtherresponsescanbefoundinAppendixO,Table5.Someofthecommentsthatpharmacistswrotewere:

Pharmacists TheBloomProgramprovidesanettostoppeoplefromslippingthroughthecracksinthecurrentmentalhealthsystems.

Theprogramhasresultedinthestafflearningmoreaboutmentalhealthissuesandtheresources that are available which I feel will help our community in the long run. …Patients seem more willing to discuss or hear about options when presented as aprogramandnotjustasuggestionfromusonacertainissue.

The Bloom Program allowed us to spend extra timewith patientswho needed it andhelp them connect with other health care providers when necessary. I also like therecording system for patient encounters as it helped keep all staff up to date on thepatients'status.

…peoplearemorecomfortabletocometoyouwithotherthingsthatmaynotevenberelatedtomentalhealth.

Theenrolmentallowsustogetathoroughhistoryandbackgroundonourpatientsthatwemaynotgetotherwise.

Pharmacistswereasked to identifyanybenefits theyexperienced related to theirparticipation in theBloom Program. The overwhelming response to this question could be themed as an increasedunderstanding of the issues facing people living with mental health and addictions, and/or moreprepared/betterabletoprovidethemwithhigherqualitycare.

Thefollowingquotesummarizesmanyoftheresponsestothisquestion.

Pharmacist I have seen several benefits at our location from this program. The first being that I

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believe it has improved our relationship with several patients. It has increased theawarenessamongststaffaboutmentalhealthresourcesthatmaybetheywereunawareofbefore.Ialsothinkthatithasresultedinstaffbeingmorecognizantofthechallengesthatmentalhealthpatients face. Ithasopenedthereeyes that therearemorepeoplelivingwithmentalhealthissuesthatarenotaccessingtheresourcesthattheyneedthanthey were aware of. It has given staff confidence in opening a conversation withsomeone about helping them that I believe would not have taken place prior to theprogram.

2. Programchallenges

Pharmacists were asked to identify what they liked least about the Bloom Program. Four themes ofrelativelyequalimportanceemergedfromthequalitativedata(Table17).

Table17:Themedresponsesofwhatpharmacistslikedleastabouttheprogram(n=25) #of

responses

Paperworkwassometimestootimeconsuming 6

Convincingpatientsofbenefits/frustrationswith‘no-shows’ 5

Schedulingchallenges 4

Patientinteractionscouldbetootimeconsuming 4

Lackofphysicianbuy-in/collaboration 2

Needmoreadvertising 2

Someofthecommentsfrompharmacistsinclude:

Pharmacists Thatthereisnotenoughawarenesstothegeneralpublicthatthisisavailabletothem.Reallyneedtogetthisoutthere.Promotetheheckouttaofit.

SometimestherewasdifficultyspendingtimewithBloomProgrampatientsastypicallynopharmacistoverlap.Couldbestressfultohaveaninitialencounterandsetupwithapatientduringbusyhours.

I'mnotsurehowonboardthedoctorsarewithit.Itseemsalittlelesscollaborativethanitisshouldbe.

Sometimesdealtwithdifficulttopicsinthecounselroomthatmayborderpsychologyvs.pharmacy.Difficulttoexplaintopatientswhatisappropriateforpsychologyvs.pharmacy.Wouldalwaysreferwhennecessary.

Pharmacistswerealsoaskedto identifyanychallengestheyexperiencedasaresultofparticipating inthe Bloom Program. Most of the challenges were related to time demands and having to schedulepatientswhentherewaspharmacistoverlap.Becauseitwasdifficulttoquantifytheresponses,onlythethemesareprovidedinTable18below.

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Table18:ThemedresponsesofchallengespharmacistsexperiencedprovidingtheBloomProgram(n=25)

Themedresponses

Pharmacystaffschedulingproblemscompoundedbypatientswhodon’tshowupforappts.

TimerequirementsforBloomProgramdeliverycanbetoomuchwithincurrentpharmacystructure

Access problems to adequate mental health and addictions services in communities means that Bloompharmacistsareaddressingaservicegapthattheymaynotbeabletofillbecauseoflackoftimeandbecausetheworkisoutsidetheirscopeofpractice(i.e.patientswantcounseling,notnon-specificsupport).

Pharmacistscan’tconductallofoutreachandnavigationalsupportpatientneed.

Thereisn’tenoughinterestonthepartofsomehealthcareprovidestocollaboratewithpharmacists.

And,someofthecommentsthatpharmacistswroteinthesurveyareasfollows:

Pharmacists Beingabletodrawthelinewithpatientsduringtheirappt.onseeingthepharmacistformedicationneedsandreferrals.MostpatientswereonlongwaitliststoseecounselorsandfoundtheBloomappts.filledthatvoidinthemeantime.Itputsthepharmacistinaposition of listening empathetically but also being in a position outside their scope ofpracticeandusingtimewithinthepharmacythatshouldn'thavebeenallocatedtothat.IfounditchallengingthattheonlyfeedbackIreceivedduringmostoftheprogramwassolelyfromthepatients.ThoughIenteredtheprogramthinkingIwouldbeinvolvedinahealthcareteamprogram,Ididnotreceivefeedbackfromfamilyphysicians,whowouldbeprimarilyresponsibleforthepatientscare.

It ishardtoschedulepatientsforappointmentswithstaffoverlapandbusydispensarytasks.Sickdays,vacations,andstaffabsenteeismmake italmost impossible todelivertheprogramanddispenseinasafemanneronsomedays.

Ithasalsobeeneyeopeningtoseethe lackofsupportthatsomepeoplearereceivingandhowdifficultitcanbetogetthemwhattheytrulyneedtobesuccessful.

Patientswouldgravitatetowardsthepharmacyinmomentsofacutepsychiatricillnessforcounsel.OnepatientresultedinEHScomingtothestore.Madememoreawareoftheneedformentalhealthfirstaid.

3. Areasforimprovement

Pharmacistswereaskedtoprovideadvicetoprogrammanagersabouttheprogram.TheadvicewasprimarilyrelatedtothreethemesoutlinedinTable19.

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Table19:ThemedresponsesofadviceforprogrammanagersfromBloomProgrampharmacists(n=25)

Themesfromtheresponsesto:‘Whatadvicewouldyougive?’

Expandtomorepharmacies;theneedanddemandforsuchaprogramisveryhigh.

Increaseprofileoftheprogramtoaidinpatientrecruitment.Moreresourcestohelppatientsandotherserviceprovidersunderstandtheintent

Increaseinterestfrom/collaborationwithotherhealthcareproviders.

Providemoreresourcestomeettheneedforsocialsupport.

Reviewfundingmodeltoensureitreflectthecostsofdeliveringtheprogram

Someofthecommentsthatpharmacistswrotewere:

Pharmacists Expand,expand.Thisisawin/winsituationandwillalsotakethestressoffofanalreadystressedmedicalfield.Weareallapartoftheteamtoincreaseawarenessandhavealotofgreatpharmacistswillingtojumpinwiththeirteamandmakethisahugesuccess.Getitoutthere.Thereissomuchroomforgrowth.

Not to underestimate the benefit of one-to-one patient counsel and monitoring withregardstomentalhealthdisease.Whenapatientissimplydispensedanewmedicationrelated to their mental health without a clear understanding of expectations andmonitoring,thefailurerateseemstoincrease.Wewereabletotroubleshootonmanyoccasionstomodifytherapyandseeminglyincreasetherate(ormoveapatientcloser)toremission.

Counseling services, having someone to talk to seemed to be the greatest need thatpatientsrequired.IfBloomwastogrow/expand/evolveitwouldbeanovelideatohave(funding)/ access to/counseling services that visit the pharmacy on a routine basis(possiblystudentsfromauniversitythatneedclinicalhours?)

The current funding model does not address the rising cost of pharmacist wages todelivertheprogramsuccessfullyinruralsettings.

Pharmacistprogramfeedbackfrominterviews

Theevaluationprocess included interviewing20pharmacists from20of23pharmacieswhoprovidedrich information on their experiences delivering the Bloom Program. This data will be analyzed in asecondarypharmacistprocessevaluationtoinformandsupportprogramimprovementsandexpansion.Giventhepurposeofthisevaluationreport,somehighlevelidentificationoffeedbackandkeyissuesiswarranted in order to assess the feasibility of continuing and expanding the program from apharmacist’sperspective.

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Rewardingwork

Overall,allpharmacistswhowere interviewedwerehighlysupportiveofdeliveringtheprogram,bothbecausetheysawsignificantneedforitwithinthecommunityforpeoplelivingwithmentalhealthandaddictions problems, and because they found working within an expanded scope of practice veryrewardingashealthcareprofessionals.

Pharmacycompensation

Withrespecttopharmacycompensationfordeliveringtheprogram,ofthe20pharmacistsinterviewed,11 said that they felt itwas adequate compensation, sevenweren’t sure if itwas or not, one said itwasn’t,andonedidnotanswerthequestion.Mostpharmacistsappearedtobelievethatpatientsoftenusedupmorethantheallottedtimeearlyonintheprogram,butlesssoastheprogramcontinuedandtheir issuesbecame improvedor resolved. Somepatientsusedupmoretimethanothers,and intheend,itusuallyworkedout.Pharmacistsalsoacknowledgedthatthereisindirectrevenuethatcomesinto the pharmacy because the program helps build their reputationwithin the public for delivering agoodservice,whichattractsbusiness.

Advicetoprogrammanagers

Most of the pharmacists interviewed said that they felt the program should continue and/or expandbecausetherewassuchahighneedforitinthecommunity.Withrespecttospecificadvice,thefollowrepresentssomegeneralinputprovided.

• Promote the programmore among the local family physician and psychiatrist community togeneratereferralsandtosupportincreasedcommunicationandbuy-infortheprogram.

• Identify among current Bloom pharmacies what is working really well, and share and refinethosepracticessothatotherpharmaciescanlearnfromtheexperiencesofothers.Thiswillhelpensuretheprogramisoptimallydeliveredforbothpharmaciesandpatients.Afewpharmacistssaid that they would have welcomed additional opportunities to learn more about mentalhealth and addictions issues commonly encountered in their Bloom Program patients. Forexample, they stated that theywouldparticipate ina facilitatedexchangeofexperiencesandinformation involving several Bloom Program pharmacists, thereby going beyond the onlinediscussionforumprovided.

Areasforimprovement

Pharmacists identified some program areas where they felt the processes could be reviewed and orissuesthatcouldbeaddressedtoimprovetheprogram.Theseinclude:

• Patient numbers: Identifying the right number of patients that the pharmacy can serve toensureprogramqualityassuranceexpectationsaremet.Thisnumberwillbepharmacyspecificand be influenced by pharmacist staff complement. Somepharmacists said that they learnedhowmanypatientstheycouldadequatelysupportoverthedurationofdeliveringtheprogram.

• Scheduling:Schedulingpatientappointmentswhenthereispharmacistoverlapisnecessarybutcanbedifficultgiventheotherdemandsonpharmacists’timewithdispensingresponsibilities.

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For somesmallerpharmacieswithvery limitedpharmacistoverlap time, thiswasachallenge.Otherpharmaciesdidnotraisethisasanissueandtheysaidthattheycouldhavehandledmorepatients.

• Communicationwithphysicians:Developingsupportfortheprogramwithlocalphysicianswasseenbyallpharmacistsasveryimportantfortheprogram’ssuccess.Somepharmacistssaidtheyhad strong support from local physicians and could build upon already well-establishedrelationships,whileothersfeltthattheyhadnointerestorsupportfromphysicians.

• Client mix: Some patients will require more support than others and providing support topharmacistsabouthowtobalance the rightmixof clientdiagnosis complexitywithpharmacystaff resources is important. Somepharmacists said that at first they hadmanypatientswhohadcomplexneeds,whichendeduptakingmorepharmacisttimethanwhattheyhadoriginallyanticipated.Eachpharmacyhasadifferentstaffcomplementsofindingtherightbalancecanbeachallengeandpharmacistsmayneedhelpbeingprepared for thisandknowinghowtodealwiththisifitbecomesanissue.

• Resourcelibrary:Reviewingwhetherthepublicresourcelibraryisanecessaryfeatureforeverypharmacymaybewarranted.Half (10)of thepharmacists interviews said thepublic resourcelibrary in thepharmacywasworth the investmentwhile five said itwasn’tutilizedenough tojustifytheexpense.Forthosewhosupportedit,theysaiditwasusedbythegeneralpublicandpatients,andithelpedtoidentifythepharmacyassupportiveofmentalhealthissues.

• ‘No-shows’:Becausepharmacistsdon’ttypicallymakeappointmentswithpatients,somewerenotusedtopatientscancellingappointmentsornotshowingup.ThisissuecouldbesomethingaddressedinaBloomPharmacybestpracticessharingforum.

• Communityoutreach:Whilepharmacistsvaluedtheopportunitytoestablishlinkageswithlocalmental health and addictions services and supports, some pharmacists expressed frustrationfromthelackofresponseand/orinterestbysomeoftheseagencies.Thismadedeliveryoftheprogram’snavigationalcomponentmoredifficult.

Some pharmacists also identified what could be termed key ingredients for the program’s success,which included:supportivepharmacyowner, interestedstaff,andongoingprogramsupport (providedinthisprojectbytheimplementationteam).

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DiscussionThevarioussourcesofdata,whentakentogetherforthisoutcomeevaluation,indicatethattheBloomProgramdemonstrationprojecthasbeensuccessful inachievingallof itsshort-termpatientoutcomesand several of its medium-term outcomes. A summary of these findings and their implications arediscussedhere.

Therewere some initial challengeswithmaking theprogramknownwithin thecommunitieswhere itwasofferedandwithhelpingpeopleunderstandhowitwouldachieveitsobjectives.Thesechallengesaretobeexpectedindemonstrationprojectsthatareofferedinlimitedsettingsandthattestnewandinnovativeapproachestoaddresscomplexhealthproblems,complexitythatisalmostalwayspresentincaringforpeoplewithmentalhealthandaddictionsproblems.Thesechallengesarealsotobeexpectedwhenattemptingtoshiftwidelyheldviewsabouttherolecommunitypharmacistscanplayinthecareandsupportofpeoplelivingwithmentalhealthandaddictionsproblems.Aswasclearfromsurveyandinterviewdata,pharmacistsaretraditionallyviewedintheirmedicationdispensaryroleandtoshiftthattoincludetheiroptimizedscopeofpracticetakestime.

OncetheBloomProgramwasfullyunderway, itbecamewell-utilizedbythetargetpopulation:90%ofenrolledpatients returned formultiple follow-upmeetingswithapharmacist,averaging5-6meetingsperpatientoverthesix-monthprogramperiod.Thishighretentionratespeakswelltothehighqualityofservicesthatpatientsreceivedinadditiontothefindingthatcloseto4in5medicationissueswereresolvedbythetimepatientsweredischarged.Fromtheoutset,acharteredprincipleof theprogramwastosupportpatientrecoveryanddischargefromtheprogram.Thisappearstohavebeenachievedforthemajorityofpatientsenteringtheprogram.

The Bloom Program clearly provided increased access to mental health and addictions services andsupportsforenrolledpatientsanditdidsoindifferentways.First,patientshadaccesstoanewprogramthatfocusedonprovidingindividualizedmedicationtherapymanagementforpatientswhohad,inmanycases, complex psychiatric and physical health problems. The approach to the identification,prioritization,andmanagementofmedicationandrelatedhealthissueswaspatient-centred,evidence-informed, and holistic.Many of the Bloom Program patients hadmultiple self-identifiedmental andphysical (e.g., cardiovascular disease, pain, diabetes, respiratory disease) health problems and weretaking several medications that included multiple psychotropic medications as well aspharmacotherapiesforphysicalillnesses.Asonephysicianarticulated,psychiatricpatientswithcomplexneeds require significant supports to live well in the community. They benefit from having multiplepeople involved intheircarewhotheycanaccessonaregularbasisandwhotogethercanhelpthemstaymotivatedtomakeandmaintainpositivechanges.Pharmacistsarelogicalmemberstoincludeinapatient’scircleofcarebecauseoftheiruniquecommunityhealthcaresetting,theiraccesstopatients,andtheirknowledge,expertiseandskills.

The second manner in which the Bloom Program increased access to mental health and addictionsservices is through the systemsnavigation supportpharmacistsprovided topatients. Thedata clearlydemonstratedthatpatientsusedandappreciatedthesupportpharmacistsgavetohelpthemnavigatewhataregenerallycomplexsystemsofmentalandphysicalhealthcare.TheBloomProgramexplicitlyrecognizesthatindividualswithmentalhealthandaddictionproblemsrequirearangeofsupportsthatnosingleagencyorhealthcareprovidercanprovide independently.TheBloompharmacyservedasa

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welcoming, neutral community health care hub that a vulnerable, highly stigmatized population feltcomfortableandsafeaccessing.

Thethirdwaythattheprogramincreasedaccesswasbyprovidinginterimsupportfor individualswhowere waiting for, had difficulty accessing, and/or were transitioning to other mental health andaddictionsservices.ManyBloomProgrampatientsweregratefultofindacaring,compassionatehealthprofessional at their local pharmacy who made themselves available to listen. This type of generalemotionalandpsychologicalsupport isaninherentfeatureofpharmacists’careofalltheirpatients. ItwasenhancedbythestructureoftheBloomProgramandfrequentlyaccessedbypatients.

Collaborationwithothermembersofthepatient’scircleofcarewasanotherfoundationalprincipleofthe programand increased collaborationwas amedium termoutcome. Because pharmacists alreadywork closelywith physicians and other prescribers, it was hypothesized that the program’s structurewould deepen those relationships and support improved communications and collaboration for thepurposesof resolvingpatientprioritizedmedicationandhealth issues. The survey and interviewdataindicated that there was a strong need and desire by physicians and pharmacists to communicateeffectively and a mutual recognition that this will result in better patient care and improved healthoutcomes. Patients indicated that they appreciate that health care providers have different butcomplementary roles to play, understand the importance of health care provider collaboration, andwanttoseemoreofit.Thisevaluationfoundmanyexampleswherecollaborationresultedinimprovedpatient health outcomes and program feedback on how communication processes can be improved,whichwillstrengthenthiscriticalaspectoftheprogram.

The Bloom Program structure supported pharmacists to work more optimally within their scope ofpractice by providing comprehensive, longitudinal patient care. As noted above, itwas expected thattherewouldbeachangeintheperceptionofpharmacistsfromsolelytheirdispensaryroletoonethatincludes providing enhanced medication therapy management, patient and care provider education,navigation,advocacy,andsocial support. Itwasdemonstrated that, aspatientsexperienced this levelanddepthofcare,theywouldcometoseeandutilizepharmacistsinamorecompletehealthproviderrole.

ImplicationsWhenpeoplelivingwithmentalhealthandaddictionsproblemsseetheirlocalpharmacistassomeoneelsethatcanprovidethemwithsafe,individualizedmentalhealthandaddictionscare,capacitytocareforpeoplewithinthispopulationisincreasedacrosstheprovince.ManyoftheBloomProgrampatientspresented with complex psychiatric illness compoundedwithmultiple physical health problems. It isforeseeable that if theprogramwaswidely available topeople across theprovince,many issues thatcurrently contribute to congesting mental health and addictions and primary care services could beaddressedandresolvedmoreefficientlyandfewerpatientswouldadvancetothestagewheretheyrelyonmorecostlycare, includingemergencydepartmentvisitsandhospitaladmissions.Thishaspositiveandpotentiallysignificantimplicationsforimprovingtheefficiencyandcost-effectivenessofthehealthcare system. One physician saw this potential and referred to the Bloom Program as preventativementalhealthcaretreatmentservice.

They[pharmacists]cansolveproblemsupstreambeforetheybecomeexpensivedisasters.

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IntegratingtheBloomProgramintothecurrenthealthsystemwillnotreplaceanyexistingservicesorsupports,butitcancomplementthembytappingintothefullscopeofpharmacistpracticeandtakingadvantageoftheuniquepositionpharmacieshave in localcommunities,particularlyruralandremoteones. It is well recognized that pharmacists have significant expertise in pharmacotherapy. As theprovince continues topromote andexpand collaborativehealth carepractices, theBloomProgram isstructured to support and operate effectively within that model of patient-centered care and makeimportant contributions to improving the lives of people living with mental illness and addictions inNovaScotia.

RecommendationsPatients, physicians, pharmacists, and mental health and addictions organizations support thecontinuationandexpansionof theBloomProgramalongwithgreatereffort toraiseawarenessof theprogram. It is also recommended that the program be better integrated and aligned with new andexistingmentalhealthandaddictionsservicesandbecomepartoftheprovince’soverallstrategytowardimprovedmental health care and outcomes. Further evaluation of the program, as it evolves from ademonstrationprojecttoamoresecureprogramwithanadjustedgovernancestructure, iswarrantedandwouldfacilitatetheevaluationoflong-termoutcomesandhealtheconomicanalyses.

ItistheopinionoftheBloomProgramSteeringCommitteethatthisprogramshouldbecomeaprogramgovernedandadministeredbytheNovaScotiaHealthAuthority.

To avoid program interruption and the added costs of re-starting the program, transition fundingsupportingthecontinuationoftheprogramisneededforJanuary1,2017.

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Appendices

A. BloomProgramCommitteeMembership

B. BloomProgramProjectCharter

C. RequiredpharmacyactivitiestodelivertheBloomProgram

D. PharmacistTrainingAgenda(sample)

E. BloomProgramPharmacyAuditProcess

F. EnrolmentForm(guide)

G. InitialAssessmentForm(guide)

H. ContactPreferencesForm(guide)

I. ProgressNotesForm(guide)

J. DischargeForm(guide)

K. LogicModelI(original)

L. LogicModelII(revisedJune2016)

M. Infographic(communitylinkages)

N. Pharmacistenvironmentalscanofcommunity-basedorganizations

O. Themedresponsesfrompatientandpharmacystaffsurveys

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AppendixA:BloomProgramCommitteeMembershipA. BloomProgramSteeringCommittee:OrganizationsandMembers

ORGANIZATIONS #Reps REPRESENTATIVE(S)NAMES

PharmacyAssociationofNovaScotia 1 AllisonBodnar

Nova Scotia College of Pharmacists(non-voting)

1 ShelaghCampbell-Palmer

Psychiatrist 1 Dr.SabinaAbidi

Familyphysician 1 Dr.Maria Alexiadis (replaced Dr. JohnPaleta)

DoctorsNovaScotia 1 KarenPyra(non-voting)

Communitymembers 2 PamFlightandJanDavison

DepartmentofHealthandWellness 1 TonyPrime(replacedLindsayMcVicar)

Communitypharmacists 2 GlennRodrigues,LennieWalser

Nova Scotia Health Authority,Addictions&MentalHealth

1 DerekLeduc

Ex-officiomembers(non-voting) 3 David Gardner, Andrea Murphy,PatriciaMurray

B. BloomProgramEvaluationAdvisoryCommittee:MembersandOrganizations

Committeemembername Organization

KarenPyra Doctor’sNovaScotia

DerekLeduc NovaScotiaHealthAuthority

PamFlight Communitymember

AllisonBodnar PharmacyAssociationofNovaScotia

Dr.DavidGardnerandDr.AndreaMurphy BloomProjectLeads,DalhousieUniversity

LisaJacobs(replacedJennDixon) BloomProgramEvaluator

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AppendixB:BloomProgramProjectCharter

PROGRAM CHARTER

THE BLOOM PROGRAM:

Community pharmacy teams partnering with Nova Scotians living with mental illness and addictions in support of improved health and wellbeing.

PRINCIPLES

The Mental Health and Addictions Community Pharmacy Partnership Program (the Bloom Program) is:

• Patient-centred • Community oriented • Evidence-informed • Holistic • Collaborative • Dedicated to informed patient care • Supportive of patient recovery and discharge from the program

COMMITMENTS

The Bloom Program and its pharmacists and pharmacies will:

• Develop and maintain linkages with community mental health organizations • Provide outreach activities to support the local mental health community • Enhance collaboration and communication with other health care providers, especially primary

care and addictions and mental health care services • Provide local and regional mental illness and addictions information and resources • Provide education and training to all pharmacy team members in participating pharmacies • Provide enhanced clinical services to registered patients including navigation, triage, and in-

depth medication therapy management • Participate in regular program assessment and improvement • Be fiscally responsible with dedicated public funds

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AppendixC:RequiredpharmacyactivitiestodelivertheBloomProgram

Pharmacies were considered eligible to deliver the Bloom Program for enhanced mental health andaddictions services upon demonstrating that they complete the following eligibility criteria outlinedbelow.

Thepharmacywill: Additionaldetails:

1. Complete a localenvironmentalscanof mental health andaddictions services andsupport groups in theircommunity.

Bloom Program pharmacists are to be familiar with local mentalhealthandaddictionsresourcesintheircommunitiestoenablethemto inform patients of these resources and facilitate the patient’saccesstothem

2. Demonstrate linkageswithlocal mental health andaddictionssupportgroups

Applicants for theBloomProgramare todemonstrate theyhaveorare in the process of establishing linkages to local organizations tomeetthiscommitment.

3. Mental health andaddictionsresourcecentre:develop and maintain amental health andaddictions resource centreaccessibletothepublic

Each Bloom pharmacy’s resource centre is to support access to: 1)information about local mental health and addictions supports,resources,andhealthcareservices;2)toolsandresourcestosupportnavigation of the mental health and addictions resources andservices; 3) information aboutmental illness and addictions; and 4)informationregardingtreatmentofmentalillnessandaddictions.

4. Inform local healthprovidersabouttheBloomProgramatyourpharmacy

Bloom Program patients will require enhanced collaborative careinvolving pharmacists and local health providers. To facilitate thebuildingofthesecollaborationsBloompharmacistsaretomeetwithand/or distribute print materials informing local health providers(e.g., family physicians, psychiatrists, psychologists, nursepractitioners,socialworkers,careworkers)

5. Notify the public that theBloomProgramisavailableatyourpharmacy

ItisimportantthatpeopleareabletolearnindependentlyabouttheBloom Program and its availability. Participation in the BloomProgram is tobenoticeable to thepublic in thepharmacybyuseofBloomProgramsignsand informationpamphletsdisplayed inpublicareas.

6. Maintain an in-pharmacyhealth professional libraryof essential mental healthand addictions andpsychotropicresources

Pharmacists will need direct access to up-to-date resources thatsupporttheirability toprovideevidence-based,patient-centredcareforpeopleintheprogram.

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7. Comprehensive livetraining of a nominatedlead pharmacist for theBloomProgram

Anominatedpharmacistwillreceiveacertificateofcompletionfromthe comprehensive collaborative Bloom training program involvingexpertpharmacists,peoplewith livedexperienceofamental illnessand addictions, simulated patients, and psychiatrists. Trainingincludesassessmentsbeforeandafterthelivetrainingdayaswellasacomprehensivesetofreadingsandonlinevideos.

8. Demonstrate thatpharmacy staffs have therequired program-relatedtrainingandorientation.

PharmacistsanddispensarystaffworkinginaBloomPharmacyaretobe fully oriented to and functional with the clinical and proceduralexpectationsoftheBloomProgram.Frontstoreandotheremployeesshouldbemadeawareof theBloomProgram, its corecomponents,andthecharter.

ABloomProgramIn-PharmacyTrainingManualguidesstafftraining

9. Establish policies andprocedures within thepharmacy related to theBloomProgram.

Pharmacies are to demonstrate a secure, organized system (eitherpaper-based or electronic) for maintaining patient records andinformation that are congruent with practice regulations related topatientinformationanddocumentation.

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AppendixD:PharmacistTrainingAgenda(sample)

8:00AM | Coffee&registration

8:30AM | Icebreakers&Introductions

8:45AM | AllAboutBloom:Charter,Projectreview,BloomQ&A

9:30AM | Case:SleeplessSally-David

10:15AM | Break

10:30AM | PharmacyParticipation:Application,Recruitment,andRetention11:25AM | Case:Sallyagain-Jason 12:15PM | Lunch

1:15PM | Case:Jerryarrives-Sabina2:30PM | Operationalizing Bloom (recruitment, retention, documentation, website, discussion

forum)–David,Paul,Andrea

3:00PM | Break

3:15PM | OperationalizingBloom,continued4:25PM | Closingremarks4:30PM | Close

BloomProgramTrainingDay

FridaySeptember25th2015,

Boardroom 14, BarringtonTower,ScotiaSquare

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AppendixE:BloomProgramPharmacyAuditProcess

On-siteAudit

Acceptable NotAcceptable

AdministratorprovidesleadBloompharmacistwithleseroutliningrequiredimprovementsand

expectaaons.

Within2weeksofreceivingleser,pharmacistcommunicatesacaonplantoaddressconcernswithameframeforcompleaon.

Administratoroffersandcoordinatessupport:oversight,peer-to-peer,training,etc.

Within12weeks,pharmacistdemonstratesresoluaonofissues.

Administratorreassesses.Extensionofferedunder

excepaonalcircumstances,approvedbysteeringcommisee

chair.

Administratorprovideswrisenconfirmaaontopharmacistthatall

condiaonshavebeenmetsaasfactorily.

Administratornoafiessteeringcommiseechairthatthepharmacyhasnotmettherequirementsandiniaates

removalprocessfromBloom.

Ifappropriate,administratorinformsNSCP

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APPENDIXF:EnrolmentForm(guide)

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APPENDIXG:InitialAssessmentForm(guide)

108

109

110

APPENDIXH:ContactPreferencesForm(guide)

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APPENDIXI:ProgressNotes(guide)

112

APPENDIXJ:DischargeForm(guide)

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APPENDIXK:BloomProgramLogicModel(Original)

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APPENDIXL:BloomProgramLogicModel(modifiedforOutcomesEvaluationreport)

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AppendixM: Pharmacists’ linking the Bloom Program to othermental healthandaddictionsprograms,supportsandservices

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AppendixN:Pharmacistenvironmentalscanofcommunity-basedorganizations

Application to the BloomProgram required pharmacists to locate and demonstrate connectionswithmentalhealthandaddictionsservices intheirregion.Thisactivityhelpedthempreparefordeliveryoftheprogram’sNavigationcomponent.Theseconnectionsweredocumentedintheapplicationpackagesubmittedbyeachpharmacy.

Bloompharmacistsidentified320communitybasedorganizationsandservicesacrosstheprovince,witheachpharmacyidentifying12localresourcesonaverage.Asagroup,Bloompharmacistsrecordedover65hours spent connectingwithpersonnel at 153of theseorganizations. The average time spent perpharmacy was 2.75 hours. The data likely underestimate the true amount of time spent forgingrelationshipsasnotallpharmaciesrecordedtimecommitmentsandongoingcollaborationbeyondtheapplicationpackagewasnotcollected.

Theuniqueorganizations and services identifiedbypharmacists are listedbelow.Manyorganizationswereidentifiedbymorethanonepharmacyasacontact.

911NovaScotia211250HomesAboriginalMentalHealthAwarenessProjectAcute Care Psychiatric Inpatient Unit (ValleyRegionalHospital)AddictionServices(Sydney)AddictionServices(MiddletonandKentville)AddictionServices(NewGlasgow)AddictionServicesDetoxUnit(Pictou)AddictionServices(PortHawkesbury)AddictionsServices(NorthSydney)AddictionsServices(Amherst)AddictionsServices(Halifax)ADDvocacyADHDandLifeSkillsCoachingAdsumHouseAdultMentalHealthEducationandTreatmentGroups(AVHChipman)AdultProtectionServicesAlcoholicsAnonymous(NorthSydney)AlcoholicsAnonymous(Amherst)AlcoholicsAnonymous(Cheticamp)AlcoholicsAnonymous(Bridgetown)AlcoholicsAnonymous(Halifax)AlcoholicsAnonymous(Sydney)AlcoholicsAnonymous(Digby)AlmonMedicalClinicAlternatives

AlzheimersSocietyNovaScotiaAnnapolis Valley Addictions Services andOpiateReplacementProgramAnnapolisValleyCrisisLineAnnapolis Valley District Health AuthorityMentalHealthAnnapolisValleyRegionalSchoolBoardAntigonishFoodBankArchwayPlaceARKAtlanticSleepApneaClinicAutumnHouseAVDClubhouseBarryHouseBayersRoadCommunityMentalHealthBeaconProgramBedford/SackvilleMentalHealthServicesBeing,Doing,BecomingClinicBelmont House (Dartmouth CommunityMentalHealth)BereavementGroupCairdeilPlaceCanadianCancerSocietySmokersHelplineCape Breton District Health Authority ChildandAdolescenceServicesCape Breton District Health AuthorityCommunity Rehabilitation and HousingCoordinatorCape Breton District Health Authority Crisis

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LineCape Breton District Health AuthorityMentalHealthCaperBaseAccess808Capital Health Addictions and Mental HealthProgramCapitalHealthMentalHealthCrisisLineChangingTidesChebucto Community Health Team at theSpryfieldCommunityWellnessCentreChebucto Connections: Mental HealthCommitteeChebuctoRoundTableChoicesChrysalisHouseClaraHughesonbehalfofBellLet'sTalkClinicalTherapist(Inverness)CMHAColchesterEastHantsBranchCMHAHalifax-DartmouthBranchCMHAKingsCountyBranchCMHALunenbergQueensBranchCMHATruroBranchCMHAYarmouthDigbyShelburneBranchColchesterEastHantsCrisisResponseServiceColchesterEastHantsHealthAuthorityMentalHealthServicesColchester East Hants Health Centre: AdultOutpatientsColchester East Hants Health Centre: ChildAdolescentandFamilyServicesColchester East Hants Health Centre:Compass, Family First, Child Adolescent &FamilyService,ADHDClinic,AutismServicesCommunityMentalHealthDartmouthCommunityMentalHealthNurse(Inverness)Community Mental Health Team (HantsCommunityHospital)CommunityResponseOfficerRCMPConnectionsClubhouseConnectionsDartmouthConnectionsSackvilleCrisisResponseServicesCrossroadsCumberlandMentalHealthDalhousieHealthServices

DepartmentofCommunityServicesDial-a-RideDigbyHospitalAddictionServicesDigbyHospitalMentalHealthServicesDigbyHospitalNicotineAddictionTreatmentDigbyWomen'sResourceCenterDirection180Dr.D.Martel(GeneralPractitioner)DrugRehabServicesEarlyAutismServices(Antigonish)EarlyPsychosisProgramEastHantsCommunityLearningAssociationEastHantsFamilyResourceCentreEatingDisordersActionGroupEatingDisordersProjectEchoCommunityHubEmergencyPsychiatricAssessmentFamiliesMatterinMentalHealthFamilyMattersFamilyPlaceResourceCenterFamilyResourceCentres(AnnapolisandKingsCounty)FamilySOSFisherman'sMemorialHospitalDetoxFisherman's Memorial Hospital Self FocusGroupFriendsinBereavementFromRecoverytoDiscoveryFutureWorx(ElmsdaleBranch)Guysborough Antigonish Straight HealthAuthorityCommunityMentalHealthGuysborough Antigonish Straight HealthAuthorityCommunityMentalHealthNursesGuysborough Antigonish Strait HealthAuthority: Adult Mental Health, Child YouthandFamilyMentalHealth,InpatientsHaleyStreetHantsHealthandWellnessTeamHantsLearningNetworkAssociationHealthPromotion&PreventionHealthyMindsCooperativeIn-patientMentalHealthCBRHInvernessCommunityHealthCentreIWKHealthCentre

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JosephHoweGroupHomeJuniperHouseKentvilleMentalHealthManagementKidsHelpPhoneLaingHouseLakeCityEmploymentServicesLeesideTransitionHouseLindsay'sHealthCentreLionsClubWestPubnicoMaggie'sPlaceMainlineNeedleExchangeMen's Health Centre (Family ServicesAntigonish)MentalHealthandAddictions(ValleyRegionalHospital)MentalHealthCrisisLineMentalHealthFirstAidMentalHealthMobileCrisisTeamMetroTurningPointMetroWorksMobileOutreachStreetHealth(MOSH)MudCreekNaomiSocietyNarcoticsAnonymousNehileyHouseNewAttitudesNew Glasglow Mental Health Services: AdultOut-patients, Adult In-patients, Seniors, Childand Adolescent Out-patients, Autism,Intensive Community-Based Treatment TeamServicesNewGlasgowFoodBankNewHopePsycho-SocialRehabilitationServiceNewHorizonsforSeniorsProgramNewLeafNorthEndCommunityHealthCenterNorth End Community Health Centre:MobileOutreachStreetHealthNorthNovaEducationalCentreYouthCentreNorthumberland Regional High School YouthCentreNovaScotia811NovaScotiaBipolarPeerSupportAllianceNova Scotia Certified Peer Support Specialist

ProgramNova Scotia Department of Health andWellness:MentalHealthNova Scotia Mental Health OutpatientProgramOpenArmsOpioidTreatmentServicesPaq'tnkekHealthCentrePathwaysPeersSupportingPeersPhoenixCentreforYouthHealthProgramPhoenixHousePictouAcademyYouthCentrePictou County Health Authority: TobaccoReductionStrategyPictouCountyHelpLinePictouFoodBankProbationOfficers(HalifaxRegionalPolice)ProjectHOPEPsychiatrist(Inverness)ptHealthandWellnessCentrePTSDEducationBoardPublicHousing(Spryfield)RCMPDigbyRecovery Group (Fisherman's MemorialHospitalAddictionsServices)RichmondCountyAdultDrop-inCentreRootsforYouthSaintPaul'sFamilyInstituteSalvation Army & Spryfield Family ResourceCentreSalvationArmyCentreofHopeSanfordFlemingHouseSchizophrenia Society of Nova Scotia:AntigonishandCapeBretonSupportGroupsSchizophrenia Society of Nova Scotia:BridgewaterSupportGroupSchizophrenia Society of Nova Scotia:DartmouthSupportGroupSchizophrenia Society of Nova Scotia: HalifaxSupportGroupSchizophrenia Society of Nova Scotia: KingsCountySupportGroupSchizophrenia Society of Nova Scotia: PictouCountySupportGroup

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SchoolsPlusSelfHelpConnectionSeniorSafetyProgramSeniorsServicesOutpatientsSexualHealthCentre(LunenbergCounty)ShareCareMentalHealthSHYFTYouthServicesYarmouthSleepwellNovaScotiaSocialWorker(Inverness)SOSSurvivorsofSuicideSupportGroupSouth Shore Health: Mental Health andAddictionServicesSouth Shore Hospital Choice and PartnershipApproach (CAPA) for Mental Health andAddictionsSpringhillDetoxificationCentreSpryfield and DistrictMental Health PlanningGroupSt.Peter'sEmergencyHealthServicesSt.Peter'sFireDepartmentSt.VincentdePaulFoodBankStFXUniversityHealthCentreStraitRichmondDetoxStraitRichmondHospitalDetoxServicesStrongestFamilies

SupportGroupforDepressionTalbotHouseTEAMWorkCooperativeTearmannHouseTheNavigatorTheYouthProjectTransitionHouseTreatmentMatchingUpstairsKitchenClubValley Regional Hospital: Mental Health andAddictionsServicesVONCaregiverSupportGroupWest Hants and Uniacke Community HealthBoardWesternKingsMemorialHealthCentreWomen'sSupportGroup(SouthShoreHealth)YarmouthAddictionsServicesYarmouth Bipolar and Schizophrenia SupportGroupYarmouthDistrictOfficeforChildWelfareYarmouth Hospital Mental Health andAddictionsServicesYourYouthHealthCentreatJLIlsley

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APPENDIX O: Themed responses from patient, physician and pharmacy staffsurveys

PATIENTS(n=32)17

Table1:Themedresponsesre:reasonswhypatientswouldrecommendtheBloomProgramtoothers(n=32)

# ofresponses

Provideshighqualitycare(generalcommentaroundbeingaveryhelpfulservice) 8

Provideswell-informededucation/advicearoundmedications 8

Providesgoodsupportivecounseling(patientdoesn’tfeelliketheyarealone) 6

Provides another needed mental health and addictions service and support in thecommunity

5

Helpsincreaseaccesstootherservicesandincreasescollaboration 2

Providesongoingsupport 2

Reducesstigmaandprovidessafeplaceforsupport 1

Didnothelp 1

Noresponse 7

Table2:Themedresponsesre:patientreasonsforwhytheBloomProgrammadeadifferenceintheirlife(n=32)

# ofresponses

Bloompharmacistprovidedhelpfulnon-specificsupport/supportivecounseling. 15

Programincreasedpatientlearningandcomfortlevelwithmedications 5

Helpnavigatingheathsystem 4

Patienthaslesshealthissues 3

Patienthasbetterrelationshipwithpharmacistwhoissupportive 3

Patientfeelsbetterabletohelpthemselves 2

17#doesnotaddupto32responsesbecausesomerespondentsgavemultipleanswers.

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Programprovidesmorementalhealthservicesinthecommunity 2

Didnothelp 1

Noresponse 4

Table3:Themedresponsesre:whatpatientslikedmostabouttheBloomProgram(n=32)

# ofresponses

Non-specificsupport/supportivecounselingfromBloompharmacist 17

RespectshownbytheBloompharmacist/Beingtreatedlikearealperson. 8

Educationaroundmedications/increasedawareness 4

Privacy,confidentiality/safety 4

Positiveoutcome 3

Increasedaccesstomentalhealthandaddictionsservicesinthecommunity 2

Thewholeprogram 2

Noresponse 3

Table4:Themedresponsesre:whatpatientslikedleastabouttheBloomProgram

Themesfromtheresponsesto:‘Whatdidyoulikeleastabouttheprogram?(n=32)* # ofresponses

NothingthatIdidn’tlikeabouttheprogram/Notapplicable 15

Lengthofprogram:Wishitwaslonger. 3

Notknowingwhattoexpect 1

Wishithappened(visits)moreoften 1

Physiciannotinvolved 1

Didn’twork 2

Noresponse 9

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PHARMACISTS(n=25)18

Table5:WhatpharmacistslikedmostabouttheBloomProgram(n=25)

# ofresponses

Providingnon-specific,one-on-onecare;betterinteractionswithpatients 10

Improvedpatientoutcomes 9

Allowedpharmacist todeliverbetterqualityof care topeople livingwithmental illnessand/oraddictions

8

Targetspopulationthatneedsincreasedaccesstomentalhealthservices 5

Allowed us to help patient navigate system; increased awareness of communityresources;increasednetworkofotherserviceproviders

3

Trainingandincreasedawarenessofprovidingservicestopeoplewithmentalhealthandaddictions

3

18Respondentsgavemultipleanswersresultingin>25answers.